Think Like a Doctor: A Terrible Leg Wound

The Challenge: Can you solve the case of a middle-aged woman with leg wounds that don’t respond to one of our most powerful antibiotics?

The Diagnosis column of The New York Times Magazine regularly asks Well readers to take on a difficult case and try to solve a diagnostic riddle. This month, you’ll find details about a patient who comes to the hospital with three terrible lesions on her leg that don’t respond to the usual treatment. You will also have access to the notes from the doctors who saw the patient and test results that provide you with the same information that the doctors who originally encountered this medical mystery had.

The first reader to offer the correct diagnosis gets a signed copy of my book “Every Patient Tells a Story” and the satisfaction of solving a case that could have given Gregory House a run for his money. Let’s get started.


The Presenting Problem

A 54-year-old woman comes to the emergency room with sores on her left leg that have been worsening for a month.

The Patient’s Story

The middle-aged woman was inspecting her leg when her roommate walked into the room. “Wow, that looks a lot worse,” he told her. “A whole lot worse.”

The woman looked at the large wounds on the back of her calf and nodded. Over the past week or so they had gotten much larger, and they were terribly painful. Just changing the bandage was excruciating, though she made herself do it every day.

“You need to go to the emergency room,” her roommate persisted. Tomorrow, she told him, definitely tomorrow. “No,” he said firmly, “we need to go now.”

And so, half an hour later the woman found herself in the emergency room of Waterbury Hospital in Connecticut, unwrapping her wounded calf for the young nurse staffing the triage desk. The nurse gasped as the leg was exposed.

The back of the woman’s calf was dominated by a sore larger than a hockey puck and shaped like the continent of Africa. Two smaller lesions flanked it. Their edges were red and angry-looking. The largest wound’s center was invisible behind a layer of purulent fluid that covered the wound and drenched the bandage. “Don’t touch it,” the woman said, sounding almost childlike in her pain and fear.

The nurse excused herself and returned with a doctor. This was an infection that would need intravenous antibiotics, he agreed after a quick look at the leg. The woman needed to be admitted to the hospital. The patient nodded in agreement. This was her first visit to a hospital in over a decade. She hated doctors and feared hospitals. But she knew that she needed to be here.

You can read the emergency department triage report and doctor’s note below.

The Doctor’s Story

Dr. Nadine Stanojevic, an internal medicine resident in her third and last year of training, called out to the medical student on duty after the emergency room doctor had filled her in. They headed down the stairs to the E.R., where they found the patient in the large treatment room on a stretcher, separated from the other patients by long white curtains. The woman was sitting up, hunched over her leg like a mother bird protecting a fledgling. Dr. Stanojevic introduced herself and the medical student, then asked about her leg.

It had all started about a month ago, the patient told them, after a painful red bump appeared on the back of her leg. She’d had other lesions like this over the past year — small, painful abscesses that would appear on her arms or legs, then open and drain and slowly heal. A similar, smaller one had appeared on her arm. But this new leg thing — this was crazy.

Initially there was just one lesion. It opened and drained, but instead of resolving as these lesions usually did, it had gotten larger and larger. The two other lesions started just a few days later. She washed the wounds every day and put antibiotic cream and sterile bandages on them, but it didn’t seem to help. She changed creams. Still, they just continued to get bigger.

And the wounds themselves were exquisitely tender. The back of her calf felt like it was on fire. She hadn’t been able to leave the house to go to her office for the past couple of weeks because of the pain. Now, even standing was excruciating.

Dr. Stanojevic could see the toll the lesions had taken on the woman. She’d clearly lost a lot of weight — the skin on her face seemed to be a couple of sizes too large, making her dark eyes look huge. Her graying hair fell in messy curls around her bony face. Neglected remnants of colorful polish streaked across her nails.

As the young doctor watched the woman slowly peel a now saturated gauze pad from around her leg, a smell suggestive of unwashed feet — the scent of pus — seeped into the room. The wound itself was horrific.

More of the Patient’s Story

Although the patient hadn’t been to see a doctor in years, she had several medical problems. She was a recovering heroin addict, participating in a methadone program to stay sober. She had high blood pressure that was well controlled with a single medication (prescribed at the methadone clinic) and arthritis in her hands, knees and feet that required daily doses of ibuprofen. An H.I.V. test done at the clinic six months earlier had come back negative. And though she’d never been tested for hepatitis C, she figured that — like almost everyone she knew — she probably had it.

On exam, the patient didn’t have a fever, and her blood pressure was normal. Her fingers were red and so swollen that the creases in the knuckles were almost invisible. (You can see pictures of her hands here.) On her left shoulder was a small abscess that was hot to the touch and tender.

The E.R. doctor had ordered a slew of labs. (You can see the laboratory results here.)

The patient was mildly anemic, though her white blood count was normal. Hepatitis serologies and an H.I.V. test had been sent, but the results were pending. Blood and wound cultures were sent.

The E.R. doctor had already started her on vancomycin, a powerful antibiotic, for a presumed infection with methicillin-resistant Staphylococcus aureus, or MRSA, a virulent bacterium that can cause abscesses and is resistant to most antibiotics. Dr. Stanojevic and the medical student discussed adding a second antibiotic but, like the E.R. doctor, decided MRSA was the most likely cause of this kind of terrible skin infection.

Dr. Stanojevic asked the surgeons to see the patient, in case the wound needed to be surgically cleaned. And she ordered an X-ray and an M.R.I. to see if the wound had infected the bone beneath. Then her beeper went off, and she and the student left the patient to see their next admission.

You can read Dr. Stanojevic’s admission note here.

A Stalled Recovery

The next day, Dr. Stanojevic thought the wounds looked a little better. The surgeons had cleaned off the yellow discharge, and the bottom of the shallow ulcer could be seen. It was red and angry-looking. The two smaller lesions were partly covered with dark scabs. (You can see what the lesions looked like — be warned: they are hard to look at — here and here.)

The young doctor was relieved to see that there was no evidence that the underlying muscle or bone was involved. But the next day, the patient’s third day in the hospital, the young doctor began to worry.

The wound looked no better, even though the patient had been on antibiotics for 48 hours. Maybe it wasn’t the right antibiotic. Normally, cultures grown from a sample of the wound would reveal the bacterial culprit and identify the antibiotic that would work best. But strangely, neither the blood culture nor the wound culture had grown out anything. Dr. Stanojevic expected to see Staph aureus because normally, Staph grows rapidly in the nutrient-filled culture dishes, but not this time. Why not? If it wasn’t MRSA, what could be eating away this woman’s leg like this?

You can review the M.R.I. and X-ray reports here.

You can review the follow-up laboratory results here.

Solving the Mystery

Now it’s your turn. Can you solve this mystery? Dr. Stanojevic did. I’ll post the answer on Friday.

Nov. 2 | Updated: Thanks for all your responses. To see the correct diagnosis, visit “Think Like a Doctor: A Terrible Leg Wound Solved.”

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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Cellphone Users Steaming at Hit-or-Miss Service

To wireless customers, cellphone networks might seem to be made out of thin air. But they are plenty vulnerable to catastrophic storms — and bringing service back can take an excruciatingly long time.

On Friday, four days after Hurricane Sandy, the major carriers — AT&T, Verizon Wireless, T-Mobile USA and Sprint — were still busily rebuilding their networks in the hardest-hit areas.

One-quarter of the cell towers in the storm zone were knocked out, according to the Federal Communications Commission. Many had no power, and their backup battery systems soon drained. The lines connecting those towers to the rest of the phone network were ripped out. Carriers deployed generators to provide power, but eventually those required more fuel — another limited resource.

In an emergency, a lack of cellphone reception can be dangerous, especially as more people have chosen to snip landlines out of their budgets. About 60 percent of American households have landlines, down from 78 percent four years ago, according to Chetan Sharma, an independent mobile analyst.

The carriers say they are trying their best to deal with an unusual disaster. But in the past, they have steadfastly objected to recommendations from regulators that they spend more money on robust emergency equipment, like longer-lasting backup batteries.

Neville Ray, chief technology officer of T-Mobile USA, said Hurricane Sandy was the biggest natural disaster he had ever dealt with and that service failures were inevitable.

“There’s an amount of preparation you can do, but depending on the size and scale and impact of the storm, it’s tough to anticipate every circumstance,” Mr. Ray said in an interview. “No degree of preparation can prevent some of those outages from happening.”

When networks fail, carriers deploy trucks, called C.O.W.’s, for cell on wheels, that act as temporary cell towers. But the companies say the challenge with deploying these trucks poststorm is connecting to power and to the wider phone network, which requires a microwave radio link to a working tower. Because of the density of the buildings in New York City, the trucks could serve only a small area, according to Mr. Ray.

The carriers have made other efforts to provide services while restoring their networks. AT&T wheeled out R.V.’s where customers could charge their phones. And it made an agreement to share networks with T-Mobile USA in the affected areas of New York and New Jersey. When customers of both companies place calls, they are carried by whichever network is available in the area.

But ultimately all of the carriers’ preparations and responses were not enough to get services running again in a hurry. Over the week the carriers reported gradual progress, and they declined to offer timelines indicating when customers could expect to have service again.

The unreliability of wireless networks may point to a bigger problem. Over the years, the phone companies have fought off regulators who want to treat them as utilities, arguing that if they are going to stay innovative, they cannot be burdened with the old rules that phone companies dealt with in the landline era. But as a consequence, there are almost no rules about what carriers have to do in an emergency, said Harold Feld, senior vice president for Public Knowledge, a nonprofit that focuses on information policy.

“With the new networks we’ve prized keeping costs down, we’ve prized flexibility and we’ve prized innovation,” said Mr. Feld, who wrote a blog post on Monday anticipating cell tower problems. “But we have not put stability as a value when we have been pushing to have these networks built out.”

Mr. Feld noted that after Hurricane Katrina in 2005, the F.C.C. recommended that carriers install backup batteries on their transmission towers that would last 24 hours, among other measures. But the carriers objected, presumably because they did not want to spend the money, he said. (Of course, 24 hours would not have been enough in many areas hit by the latest storm.)

In general, the carriers say it is in their own interest to fortify their networks for emergency situations, but Mr. Feld said this incentive was not enough.

“We ought to actually be doing this in the mind-set that there need to be actual rules, so that everybody knows how to behave when the crisis hits,” he said. “When I drive I have the best incentive in the world not to hit a telephone pole and not to slam into another car. But I still need speed limits, stop signs and stop lights.”

Debra Lewis, a spokeswoman for Verizon Wireless, said no amount of rules could have prepared carriers for the outcome of a storm like Hurricane Sandy.

“The fact is, regulation cannot anticipate the varied challenges that can arise in such situations, but we do learn from them and adapt accordingly to ensure we meet consumers’ needs,” Ms. Lewis said. She said the company prepared for natural disasters with generators and batteries that provided at least eight hours of power to cell sites.

Verizon Wireless said Friday evening that less than 3 percent of its network in the Northeast was still down. “In severely impacted areas, such as Lower Manhattan, while wireless service has yet to return to normal levels, coverage is good,” it said.

AT&T was the only major carrier that would not go into specifics about how much of its network was down. Anecdotally it seemed that in Manhattan at least, AT&T’s coverage was not as good as Verizon’s after the storm. One Twitter user directed this message at AT&T on Tuesday: “I live in lower manhattan. Vz has service u do not. You are ruining lives. I had to come midtown 2 call mom. Switching.”

Mark Siegel, a spokesman for AT&T, said the company would not comment because it was working on restoring its network.

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Petraeus’s Lower C.I.A. Profile Leaves Benghazi Void

WASHINGTON — In 14 months as C.I.A. director, David H. Petraeus has shunned the spotlight he once courted as America’s most famous general. His low-profile style has won the loyalty of the White House, easing old tensions with President Obama, and he has overcome some of the skepticism he faced from the agency’s work force, which is always wary of the military brass.

Brendan Smialowski/Getty Images

The low-profile style of David H. Petraeus, right, has won the loyalty of the White House, easing old tensions with President Obama.

Win Mcnamee/Getty Images

C.I.A. director, David H. Petraeus, right, appeared before the Senate Select Committee on Intelligence in Washington in January.

But since an attack killed four Americans seven weeks ago in Benghazi, Libya, his deliberately low profile, and the C.I.A.’s penchant for secrecy, have left a void that has been filled by a news media and Congressional furor over whether it could have been prevented. Rather than acknowledge the C.I.A.’s presence in Benghazi, Mr. Petraeus and other agency officials fought a losing battle to keep it secret, even as the events there became a point of contention in the presidential campaign.

Finally, on Thursday, with Mr. Petraeus away on a visit to the Middle East, pressure from critics prompted intelligence officials to give their own account of the chaotic night when two security officers died along with the American ambassador, J. Christopher Stevens, and another diplomat. The officials acknowledged for the first time that the security officers, both former members of the Navy SEALs, worked on contract for the C.I.A., which occupied one of the buildings that were attacked.

The Benghazi crisis is the biggest challenge so far in the first civilian job held by Mr. Petraeus, who retired from the Army and dropped the “General” when he went to the C.I.A. He gets mostly high marks from government colleagues and outside experts for his overall performance. But the transition has meant learning a markedly different culture, at an agency famously resistant to outsiders.

“I think he’s a brilliant man, but he’s also a four-star general,” said Senator Dianne Feinstein, the chairwoman of the Senate Intelligence Committee. “Four-stars are saluted, not questioned. He’s now running an agency where everything is questioned, whether you’re a four-star or a senator. It’s a culture change.”

Mr. Petraeus, who turns 60 next week, has had to learn that C.I.A. officers will not automatically defer to his judgments, as military subordinates often did. “The attitude at the agency is, ‘You may be the director, but I’m the Thailand analyst,’ ” said one C.I.A. veteran.

Long a media star as the most prominent military leader of his generation, Mr. Petraeus abruptly abandoned that style at the C.I.A. Operating amid widespread complaints about leaks of classified information, he has stopped giving interviews, speaks to Congress in closed sessions and travels the globe to consult with foreign spy services with little news media notice.

“He thinks he has to be very discreet and let others in the government do the talking,” said Michael E. O’Hanlon, a Brookings Institution scholar who is a friend of Mr. Petraeus’s and a member of the C.I.A.’s advisory board.

Mr. Petraeus’s no-news, no-nonsense style stands out especially starkly against that of his effusive predecessor, Leon E. Panetta, who is now the defense secretary.

Mr. Panetta, a gregarious politician by profession, was unusually open with Congress and sometimes with the public — to a fault, some might say, when he spoke candidly after leaving the C.I.A. about a Pakistani doctor’s role in helping hunt for Osama bin Laden, or about the agency’s drone operations.

Mr. Petraeus’s discretion and relentless work ethic have had a positive side for him: old tensions with Mr. Obama, which grew out of differing views on the wars in Iraq and Afghanistan, appear to be gone. Mr. Petraeus is at the White House several times a week, attending National Security Council sessions and meeting weekly with James R. Clapper Jr., the director of national intelligence, and Thomas E. Donilon, Mr. Obama’s national security adviser. Mr. Donilon said recently that the C.I.A. director “has done an exceptional job,” bringing “deep experience, intellectual rigor and enthusiasm” to his work.

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Estimate of Economic Losses Now Up to $50 Billion

Economic damages inflicted by Hurricane Sandy could reach $50 billion, according to new estimates that are more than double a previous forecast. Some economists warned on Thursday that the storm could shave a half percentage point off the nation’s economic growth in the current quarter.

Losses from the storm could total $30 billion to $50 billion, according to Eqecat, which tracks hurricanes and analyzes the damage they cause. On Monday, before the storm hit the East Coast, the firm estimated $10 billion to $20 billion in total economic damages.

The flooding of New York’s subways and roadway tunnels and the extensive loss of business as a result of utility failures across the region were behind the sharp increase in the estimate, the firm said.

“The geographic scope of the storm was unprecedented, and the impacts on individuals and on commerce are far larger,” said Tom Larsen, Eqecat’s senior vice president and product architect. “Lost power is going to contribute to higher insurance losses.”

Eqecat predicted that New York would bear 34 percent of the total economic losses, with New Jersey suffering 30 percent, Pennsylvania 20 percent and other states 16 percent. That includes all estimated losses, whether covered by insurance or not. The estimates and the share that will be covered by insurers are far from certain at this point, as government officials, property owners and insurance adjusters struggle to assess the destruction.

While the stock market, banks and other financial institutions regained some of their stride on Thursday, other sectors like retailing, transportation and leisure and hospitality face a much longer and more difficult recovery. With fuel in short supply in many areas and utilities warning that power may not be back for a week or more in some areas, businesses found themselves preparing for the equivalent of a long siege.

FedEx, for example, was trying to rent fuel tankers for its trucks in New York and New Jersey as commercial gas stations ran dry.

“We’re reaching out to everyone who has a gasoline tanker that we can move to these areas,” said Shea Leordeanu, a spokeswoman for the company. While FedEx had stocks of oil in advance of the storm for generators, it was not prepared for the gas shortages that caused long lines at stations on Wednesday and Thursday.

“There has not been an impact yet, but this is something we can see as an issue and we’re concerned,” she said.

As logistical problems mounted, and damage estimates surged, economists raised their estimates of the storm’s impact.

“I think the effect will be quite big,” said Julia Lynn Coronado, chief economist for North America at BNP Paribas. “In the fourth quarter, we’re probably looking at an impact of half a percentage point.”

She said some of those losses would be made up in the first quarter of 2013, as insurance reimbursements were distributed and homeowners and businesses rebuilt.

Hurricane Sandy will rank high among disasters in terms of economic impact but will not be at the top of the list, said Mark Zandi of Moody’s Analytics. He estimated that the losses would be less than half of those suffered because of the 9/11 terrorist attacks and from Hurricane Katrina.

Moody’s Analytics also put the impact in the $50 billion range, with about $12 billion in losses falling in the New York City metropolitan area.

About $20 billion of that total is from lost economic activity like meals not served in restaurants, canceled plane flights and bets not placed in casinos, Mr. Zandi estimated. The rest, about $30 billion, will be from property destruction, including damage to homes, cars and businesses, Mr. Zandi said.

Eqecat said it believed that various forms of insurance would cover $10 billion to $20 billion of the total cost. Other losses will be borne by individuals and businesses, or covered by federal government programs like the National Flood Insurance Program. Much of the federal spending will be used to repair damaged public infrastructure, rather than for private property.

Eqecat said that if insured costs remained at the lower end of its predicted range, at $10 billion, then about 60 percent of the losses would be covered by homeowners’ and, to a lesser extent, auto insurers. The remainder would be covered by commercial and industrial insurance.

The firm’s officials said that if total insured losses rose to the higher end of its predicted range, it would be because of costs like business-interruption losses — and in that case, commercial insurers pay more.

They said this possibility would depend to a great extent on how long power failures continued. They said there were no solid data yet on the number of transformers and power lines that had been knocked out. They added that in some cases, power might not be restored until well into December.

Moody’s issued a report on Thursday stating that the large nationwide insurers had “diversified exposures and strong capital bases to withstand” payouts related to the storm. It added, however, that the costs could disrupt the capital bases of smaller regional insurers.

State Farm, the largest writer of home and auto insurance in the region, reported having received nearly 25,000 homeowners’ claims and 4,000 auto claims as of Wednesday. Those numbers are probably a fraction of the eventual totals. Some of the losses will not be recouped. Lost Halloween sales will be especially painful for some retailers, according to a separate analysis by Moody’s.

“As shoppers in the affected regions focus on the storm, other discretionary spending will fall and not be recouped,” Moody’s said.

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Safety of Monster Energy Drinks Questioned

In the latest action aimed at the energy drink industry, the top lawyer for the city of San Francisco has asked one major producer to provide evidence that supports the advertising and marketing claims it made to adolescents for its highly caffeinated drinks.

In a letter sent late Wednesday to Monster Beverage, the city attorney of San Francisco, Dennis J. Herrera, told the company to substantiate its claim that large daily quantities of Monster Energy were safe for adolescents and adults.

Mr. Herrera also told Monster, a publicly traded company, to produce support for its promotional slogans, like one that claims that consumers of Monster Energy “can never get too much of a good thing!”

In taking the action, Mr. Herrera cited a section of a California state law that makes it illegal for a company to make false or misleading advertising claims that purport to be based on fact or clinical data.

In a statement, Monster Beverage said: “The company can document the legal basis by which its products are properly labeled dietary supplements, and third party scientific documentation substantiates their safety.”

The energy drink industry and Monster Beverage in particular has come under intensifying scrutiny since last week after disclosures that the Food and Drug Administration had received reports that the deaths of five people since 2009 may be linked to Monster Energy drinks.

The company has repeatedly disputed any suggestion that its drinks pose a risk. The F.D.A., which said it was looking into the episodes, added that the receipt of a death or injury filing associated with a product did not mean that it was responsible.

Last week, two Democratic lawmakers, Senator Richard J. Durbin of Illinois and Senator Richard Blumenthal of Connecticut, sent the latest of several letters to the F.D.A. commissioner, Margaret Hamburg, urging the agency to take action on energy drinks.

The agency has taken the stance that there is insufficient data to take additional action on energy drinks. Both Democratic lawmakers have been critical of that position.

The New York State attorney general is investigating the practices of several producers.

In his letter Wednesday, Mr. Herrera asserted that Monster Beverage, through its advertising and marketing claims, had encouraged “unsafe and irresponsible consumption of its products.”

Monster Energy drinks do not disclose caffeine levels. But product labels advise against drinking more than three of the 16-ounce cans or two of the 24-ounce cans daily, amounts that each contain a total of 480 milligrams of caffeine.

The F.D.A. has suggested that 400 milligrams of caffeine a day from all sources is safe for adults, although many medical experts believe that adults can safely consume more. There is far less data about safe caffeine levels for teenagers.

Read More..

Safety of Monster Energy Drinks Questioned

In the latest action aimed at the energy drink industry, the top lawyer for the city of San Francisco has asked one major producer to provide evidence that supports the advertising and marketing claims it made to adolescents for its highly caffeinated drinks.

In a letter sent late Wednesday to Monster Beverage, the city attorney of San Francisco, Dennis J. Herrera, told the company to substantiate its claim that large daily quantities of Monster Energy were safe for adolescents and adults.

Mr. Herrera also told Monster, a publicly traded company, to produce support for its promotional slogans, like one that claims that consumers of Monster Energy “can never get too much of a good thing!”

In taking the action, Mr. Herrera cited a section of a California state law that makes it illegal for a company to make false or misleading advertising claims that purport to be based on fact or clinical data.

In a statement, Monster Beverage said: “The company can document the legal basis by which its products are properly labeled dietary supplements, and third party scientific documentation substantiates their safety.”

The energy drink industry and Monster Beverage in particular has come under intensifying scrutiny since last week after disclosures that the Food and Drug Administration had received reports that the deaths of five people since 2009 may be linked to Monster Energy drinks.

The company has repeatedly disputed any suggestion that its drinks pose a risk. The F.D.A., which said it was looking into the episodes, added that the receipt of a death or injury filing associated with a product did not mean that it was responsible.

Last week, two Democratic lawmakers, Senator Richard J. Durbin of Illinois and Senator Richard Blumenthal of Connecticut, sent the latest of several letters to the F.D.A. commissioner, Margaret Hamburg, urging the agency to take action on energy drinks.

The agency has taken the stance that there is insufficient data to take additional action on energy drinks. Both Democratic lawmakers have been critical of that position.

The New York State attorney general is investigating the practices of several producers.

In his letter Wednesday, Mr. Herrera asserted that Monster Beverage, through its advertising and marketing claims, had encouraged “unsafe and irresponsible consumption of its products.”

Monster Energy drinks do not disclose caffeine levels. But product labels advise against drinking more than three of the 16-ounce cans or two of the 24-ounce cans daily, amounts that each contain a total of 480 milligrams of caffeine.

The F.D.A. has suggested that 400 milligrams of caffeine a day from all sources is safe for adults, although many medical experts believe that adults can safely consume more. There is far less data about safe caffeine levels for teenagers.

Read More..

Sony, Sharp and Panasonic Report Significant Losses

TOKYO — After years of bets gone wrong and lost opportunities, three of Japan’s consumer electronics giants are showing some signs of faltering.

In the most dire warning, Sharp forecast on Thursday a 450 billion yen ($5.6 billion) full-year loss and warned that it had “material doubts” about its ability to survive.

On the same day, Panasonic’s shares lost a fifth of their value in Tokyo after the company forecast a 765 billion yen ($9.6 billion) annual net loss from write-downs in its solar-power, battery and mobile handset businesses.

And Sony, perhaps the best positioned of the companies, posted a net loss of 15.5 billion yen ($194 million) for the quarter on Thursday and warned of falling sales in almost every product it sells.

“We have a lot of great technology which we want to tap to revive and generate profit, but the company does not have that vitality,” Takashi Okuda, Sharp’s chief executive, told reporters after the company posted a net loss of 249 billion yen ($3.1 billion) for the three months to September. The loss was far larger than expected.

In a statement, the company said it had a “serious negative operating cash flow” which raised “serious doubts” about its ability to continue as a going concern, and said it was taking steps, including pay cuts, voluntary redundancies and asset sales, to generate cash flow.

While Sharp is in the most serious trouble, the three companies’ woes are similar at the core.

All three make good quality, even cutting-edge products — but so do their overseas competitors, usually at lower prices. None of the three have managed to generate the brand pizazz of Apple, or the marketing muscle of Samsung Electronics. In addition, a stubbornly strong yen continues to sap their competitiveness, while Japan’s territorial dispute with China has hurt sales there.

The scale of the losses is the result of specific missteps, from huge investments in the wrong technologies to a reluctance to exit loss-making businesses. A manufacturing bubble here in the mid-2000s — fed partly by an unusually weak currency and Americans flush with cash from rising home prices — masked continued weaknesses in their business models and spurred the companies to take big bets that backfired.

When the global financial crisis brought that boom to an end in 2008, the three were saddled with excess capacity, bloated work forces and investments that they could hardly hope to recoup. And their refusal to make a big enough departure from the ways of their glory years is now making a comeback difficult.

“Many investors are longing for reforms that will let all of the pus out,” Yuji Fujimori, technology analyst at Barclays Capital in Tokyo, said in a recent note to clients.

Sharp’s stumble, in many ways, has been the most humbling. It was the biggest beneficiary of the manufacturing bubble: from 2000 to 2007, its profits jumped 150 percent. Sharp’s high-end Aquos liquid-crystal display televisions — which it manufactured at state-of-the-art factories in Kameyama, in western Japan — were a runaway hit in the nascent flat-panel market. The spinoff Aquos cellphone topped Japanese sales rankings. Sharp’s solar batteries also sold briskly, helped by a bubble in green technologies.

The company’s success during this period seemed to validate Japan’s penchant for manufacturing their most important products in-house. In advertisements, Sharp showed off its cutting-edge factories.

But even before the financial crisis, analysts were warning of an impending crash in prices of flat-panel televisions, which were fast becoming commodities that cheap upstarts could emulate. In 2008, the iPhone made its debut in Japan, the end of an era for Japanese-style cellphones. Chinese upstarts were starting to flood global markets with cheap solar panels and batteries. In consumer electronics, outsourced manufacturing became the norm.

Still, Sharp did not change course. It built a new factory in Sakai, Japan, which could make 6 million large LCD panels a year — more than the size of the global market at the time. Sharp missed the smartphone wave, and its cellphone sales in Japan halved from 2007 to 2012. And in late 2011, the solar bubble burst, driving many solar power companies into bankruptcy and Sharp’s solar batteries business into the red. The unit has not turned a profit since.

Now, the Kameyama factories no longer make televisions but panels for Apple’s iPhones and iPads.

Panasonic, for its part, also bet heavily on plasma televisions in 2003, pouring some 600 billion yen into a series of factories in Amagasaki, not far from Sharp’s own plant. It also bet on solar panels and rechargeable batteries, buying Sanyo in 2009.

But with plasma now a fading technology and solar power struggling, Panasonic is saddled with major losses. Last year, it announced that a factory in Amagasaki was closing, less than two years after it opened.

Kazuhiro Tsuga, who took the helm at Panasonic this year, was blunt in describing his company’s predicament. “We are among the losers in consumer electronics," he told a news conference on Wednesday. He now promises to shift the company away from money-losing televisions and gadgets.

Of the three, Sony now seems the most prescient. Its executives have preached the power of networks and content since the 1990s, building up a vast catalog of music and movies to lure users to their devices. Sony has also moved to slash costs and jobs and sell off some unprofitable businesses, refocusing the company on digital cameras and imaging technology, video games and mobile devices. This quarter, the sale of its chemical products business, which made materials for LCDs and optical discs, helped alleviate losses. Sony is now making a push into the medical field with an investment in the endoscope maker Olympus.

Internal squabbling has quashed its efforts to marry its hardware and software, however, and it refuses to abandon one of its biggest money-losers, its television business, which has bled red ink for eight consecutive years.

“We intend to hunker down and build a profitable business,” Masaru Kato, Sony’s chief financial officer, told a news conference Thursday. “And where we can, we will chase new markets.”

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Live Coverage: Increments of Progress, and New Struggles, After Storm

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State-by-State Guide

A look at the devastation caused in the aftermath of Hurricane Sandy from North Carolina to New England.

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Apple Shake-Up Could End Real-World Images

Whether they realize it or not, all of those who swipe a finger down from the top of the iPhone’s screen to check for notifications are bearing witness to a big sore point within Apple.

Justin Sullivan/Getty Images

Jonathan Ive, second from left, who will oversee the look of Apple’s software, is said to have criticized the images in the company’s mobile software. More Photos »

There, behind a list of text messages, missed phone calls and other updates, is a gray background with the unmistakable texture of fine linen.

Steven P. Jobs, the Apple chief executive who died a year ago, pushed the company’s software designers to use the linen texture liberally in the software for the company’s mobile devices. He did the same with many other virtual doodads that mimic the appearance and behavior of real-world things, like wooden shelves for organizing newspapers and the page-flipping motion of a book, according to people who worked with him but declined to be named to avoid Apple’s ire.

The management shake-up that Apple announced on Monday is likely to mean that Apple will shift away from such visual tricks, which many people within the company look down upon. As part of the changes, the company fired Scott Forstall, the leader of Apple’s mobile software development and a disciple of Mr. Jobs. While Mr. Forstall’s abrasive style and resistance to collaboration with other parts of the company were the main factors in his undoing, the change also represents the departure of the most vocal and high-ranking proponent of the visual design style favored by Mr. Jobs.

The executive who will now set the direction for the look of Apple’s software is Jonathan Ive, who has long been responsible for Apple’s minimalist hardware designs. Mr. Ive, despite his close relationship with Mr. Jobs, has made his distaste for the visual ornamentation in Apple’s mobile software known within the company, according to current and former Apple employees who asked not to be named discussing internal matters.

This may seem like little more than an internal disagreement over taste. But Apple venerates design like few other companies of its size, and its customers have rewarded it handsomely as a result. Apple’s decisions can influence how millions of people use and think about digital devices — not only its own but those made by other companies that look to Apple as a standard-setter in design.

Axel Roesler, associate professor and chairman of the interaction design program at the University of Washington, says Apple’s software designs had become larded with nostalgia, unnecessary visual references to the past that he compared to Greek columns in modern-day architecture. He said he would like to see Mr. Ive take a fresh approach.

“Apple, as a design leader, is not only capable of doing this, they have a responsibility for doing it,” he said. “People expect great things from them.”

Steve Dowling, an Apple spokesman, declined to comment.

Apple’s customers do not seem to have serious qualms about the design choices the company has made as they continue to buy iPhones and iPads at a healthy clip. But within the circles of designers and technology executives outside Apple who obsess over the details of how products look and work, there has been a growing amount of grumbling in the last year that Apple’s approach is starting to look dated.

The style favored by Mr. Forstall and Mr. Jobs is known in this crowd as skeuomorphism, in which certain images and metaphors, like a spiral-bound notebook or stitched leather, are used in software to give people a reassuring real-world reference.

In contrast, Microsoft, not known as a big risk-taker, has been praised recently for taking greater creative risks in the design of its software than Apple has. It has come up with a visual style that is now used throughout its computer, mobile and game products. It relies heavily on typography and sheets of tiles that provide access to programs and are updated with photos and other online information. It is not yet clear whether this approach will be a hit with people who do not spend time thinking about design.

Bill Flora, a former Microsoft designer who created the earliest prototypes of its new visual style, said Apple had not been innovative enough in the design of its software. “I have found their hardware to be amazing and sophisticated, and I have found their software to be kind of old school,” said Mr. Flora, who now has his own design firm, Tectonic, in Seattle. “Their approach really wasn’t what I was taught as a designer in design school.”

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Adults Catch the Gymnastics Bug

Chang W. Lee/The New York Times

Adults gymnastics class at Chelsea Piers, where revenue for the program jumped 76 percent during the Olympics this year, compared with the same two weeks in 2011.

FOR Carmen Hernandez, something flipped last summer when Gabby Douglas did.

Watching the bubbly gymnast win two Olympic gold medals, Ms. Hernandez, 40, whose previous workouts were exactly as daredevil as her home elliptical machine, said she thought, “God, it would be so cool if I could try something like that.”

She was wary of injury, so she took a cautious approach to her $28 classes at Sky Zone (a chain of basketball-court-size trampolines), slowly mastering jumps and leaps.

“I can jump up in the air and touch my legs, and my core is so much stronger, so maybe I could do a flip soon,” she said proudly.

Ms. Hernandez, a Santa Monica, Calif., digital media consultant and mother of one, added, “I would never have imagined that at my age I’d be trying to do things that I wouldn’t have done as a kid.”

A rise in the number of children signing up for gymnastics classes after watching the Olympic Games is now as predictable as the arrival of the Games themselves (which is to say, so predictable that some organizations like the Y.M.C.A. Woodmont Program Center in Arlington, Va., brace for demand by hiring extra instructors). But now adult women are leaping, if not backflipping, to channel their inner Gabby.

Watching Olympic gymnastics is “almost like a reminder, like an alarm clock went off,” said Salil Maniktahla, owner of Urban Evolution gyms in suburban Washington. “They see people on TV doing amazing things, and then they look in the mirror and think, ‘What happened to me?’ ”

Mr. Maniktahla in September asked an adult beginner class at his Alexandria, Va., location how many of them turned up because of the Olympics. Half raised their hands, he said. Other anecdotal evidence abounds: Erica Schietinger, a spokeswoman for Chelsea Piers in Manhattan, said revenue for the sports center’s adult gymnastics program jumped 76 percent during the Olympics, compared with the same two weeks in 2011. Video and fan Web site Gymnastike clocked a 50 percent jump in visits to its nationwide directory of adult classes in August, according to site figures. And in the two weeks after the London Games, Sky Zone had a 20 percent increase nationwide in attendance at its gymnastics-inspired adult aerobics class, where participants frequently try tumbles and flips.

“I don’t think I bounce as high as some of the other people in the class because I do get scared,” said the actress Candace Cameron Bure, 36, who began attending Sky Zone’s classes in August. So far Ms. Bure, perhaps best known for her childhood role as D. J. Tanner on ABC’s “Full House,” has stuck to jumps like pikes and one she called “moving seat drops,” but she said she planned to channel Gabby’s determination and try a flip. “Who isn’t inspired by the Olympics?” she said. “And my kids can flip. So I have to at least try.”

Also propelling gymnastics’ rise in popularity among adults: This year, competitors in their 20s and 30s outnumbered teenagers like Gabby, 16, according to figures posted by Masters Gymnastics, an organization that promotes “gymnastics for grown-ups.” An article in The Atlantic Monthly wondered if — 40 years. after a pig-tailed Olga Korbut backward-aerial-somersaulted her way to being the sport’s first teen star — the era of the “little-girl gymnast” was ending. (Probably not.)

“When I looked at the gymnasts 12 years ago, I wanted to throw a sandwich at them,” said Edith Halasik, 38, of Chicago. “Years ago I wouldn’t have been interested in a gymnast’s body. But Gabby and the girls today look healthier and stronger. You see their muscles, not their ribs. For me, that was the attraction.”

So Ms. Halasik began driving an hour each way (dazzled by the promise of instruction by a Mongolian national circus alumna) to take 90-minute beginner’s classes at the Actor’s Gymnasium in Evanston, Ill., where 10 sessions cost $178. Ms. Halasik is a personal trainer and ultramarathoner, but fitness credits don’t necessarily transfer: It took her four weeks to pull off a handstand, she said. Next up: flips.

“Sure, I can flip,” she said, pausing to add that she lands on her backside.

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