Monthly Archives: August 2017

OIG audit: Abuse in nursing homes often goes unreported to police, despite federal law

by Paige Minemyer | FierceHealth  Aug 29, 2017 12:50pm

More than a quarter of possible abuse cases in nursing homes go unreported to police, according to a federal audit that suggests Medicare is at fault for failing to enforce reporting requirements.
The U.S. Department of Health & Human Services Office of Inspector General issued an early alert as the audit continues, including investigation results from 33 states. The results were issued early, according to OIG, as the findings (PDF) were alarming enough to warrant immediate attention.
Federal law requires that nursing homes report potential incidents of abuse to law enforcement within two hours if there is a case of serious injury, or within a day otherwise. Civil monetary fines could reach $300,000 for skilled nursing facilities that fail to comply.
Illinois had the highest number of abuse cases identified in the report, with 17. In 28% of cases, the investigators could find no evidence in records to suggest that nursing facility staff had reported the incident to police, though federal law requires it.
In one case cited in the report, an elderly nursing home resident who had mobility and verbal limitations was taken to the emergency room after an alleged sexual assault by a male resident.
But nursing home staff bathed her and changed her clothes after the incident, potentially eliminating evidence that would be needed for a rape kit, and did not report the alleged attack to police. The woman’s family was notified the next day, and they contacted law enforcement instead, according to the OIG.
The results suggest that the Centers for Medicare & Medicaid Services have inadequate procedures to make sure potential abuse cases are identified and appropriately reported. CMS has not taken any enforcement actions on the reporting laws since they went into effect in 2011, according to the OIG.
CMS said it did not enforce the regulation because the HHS secretary had not authorized it to, according to the report. The OIG offered several steps CMS should take to better protect nursing home patients, including authorization for enforcement. The agency must also take steps to compare data and better identify possible cases of abuse.
Once it can enforce reporting requirements, CMS must strive to adjust regulations as needed and make sure its State Operations Manual is up to date with the requirements. The OIG said it will offer further recommendations when the audit is fully complete.

4 strategies to reduce ER overcrowding

by Paige Minemyer | FierceHealth  Aug 29, 2017 10:56am

Overcrowded emergency rooms are common in hospitals across the country. But several key strategies unite the facilities that are most effectively tackling this problem, according to a new study.
Researchers stratified hospitals into three groups based on data from the Centers for Medicare & Medicaid Services: highest-performing, high-performing and low-performing, according to the Annals of Emergency Medicine study.
They chose a representative sample of 12 hospitals, four from each group, and interviewed 60 leaders across those hospitals to determine what was working to reduce overcrowding.
Four strategies, which could be replicated in other hospitals, were identified:
1. Executive buy-in: Leaders in the highest-performing hospitals had identified overcrowding as a key problem for them to solve, setting goals and providing the resources to accomplish them.
2. Responses coordinated across the hospital: Hospitals in the low-performance group often operated in silos, while the highest-performing deployed strategies that required coordination between departments.
3. Use of data: High-performing hospitals gathered and leveraged data to adjust ER operations in real time and to provide feedback to key staff members. Predictive analytics allowed ER staff to map needs and estimate patient flow.
4. Accountability: The highest-performing hospitals addressed issues immediately and held staff members accountable.
Benjamin Sun, M.D., a professor of emergency medicine at Oregon Health & Science University and the study’s senior author, said in an announcement that overcrowded ERs can be dangerous for patients, so finding a solution to the issue is crucial.
“Emergency department crowding can be dangerous for patients,” he said. “We know, for example, that emergency department crowding can lead to delays in pain medications for patients with broken bones, as well as delays in antibiotics for patients with pneumonia. We know the risk of death is higher when the emergency department is more crowded than when it’s less crowded.”
Hospitals have deployed a number of programs aimed at reducing overcrowding in the emergency department. Baptist Health South Florida, for instance, introduced “tele-triage” to address patients with minor injuries or other common, but not urgent, maladies.
Others have hired “bed czars” to monitor flow in the ED or have launched fast-track programs to speed up treatment for patients with minor needs.

Elder abuse: ERs learn how to protect a vulnerable population

by Barbara Sadick, Kaiser Health News | FierceHealth    Aug 28, 2017 2:21pm

Abuse often leads to depression and medical problems in older patients—even death within a year of an abusive incident.
Yet, those subjected to emotional, physical or financial abuse too often remain silent. Identifying victims and intervening poses challenges for doctors and nurses.
Because visits to the emergency room may be the only time an older adult leaves the house, staff in the ER can be a first line of defense, said Tony Rosen, founder and lead investigator of the Vulnerable Elder Protection Team (VEPT), a program launched in April at the New York-Presbyterian Hospital/Weill Cornell Medical Center ER.
The most common kinds of elder abuse are emotional and financial, Rosen said, and usually when one form of abuse exists, so do others. According to a New York study, as few as 1 in 24 cases of abuse against residents age 60 and older were reported to authorities.
The VEPT program—initially funded by a small grant from The John A. Hartford Foundation (a Kaiser Health News funder) and now fully funded by the Fan Fox and Leslie R. Samuels Foundation—includes Presbyterian Hospital emergency physicians Tony Rosen, M.D., Mary Mulcare, M.D., and Michael Stern, M.D. These three doctors and two social workers take turns being on call to respond to signs of elder abuse. Also available when needed are psychiatrists, legal and ethical advisers, radiologists, geriatricians and security and patient-services personnel.
“We work at making awareness of elder abuse part of the culture in our emergency room by training the entire staff in how to recognize it,” said Rosen. It’s easy for the ER staff to alert the VEPT team and begin an investigation, he said.
A doctor interviews the patient and conducts a head-to-toe physical exam looking for bruises, lacerations, abrasions, areas of pain and tenderness. Additional testing is ordered if the doctor suspects abuse.
“Unlike with child abuse victims, where there is a standard protocol in place for screening, there is no equivalent for the elderly, but we have designed and are evaluating one,” said Rosen.
The team looks for specific injuries. For example, radiographic images show old and new fractures, which suggest a pattern of multiple traumatic events. Specific types of fractures may indicate abuse, such as midshaft fractures in the ulna, a forearm bone that can break when an older adult holds his arm in front of his face to protect himself.
When signs of abuse are found but the elder is not interested in cooperating with finding a safe place or getting help, a psychiatrist is asked to determine if that elder has decision-making capacity. The team offers resources but can do little more if the patient isn’t interested. They would have to allow the patient to return to the potentially unsafe situation.
Patients who are in immediate danger and want help or are found not to have capacity may be admitted to the hospital and placed in the care of a geriatrician until a solution can be found. Unlike with children and Child Protective Services, Adult Protective Services won’t become involved until a patient has been discharged, so hospitalization can play an important role in keeping older adults safe.
During the first three months of the program, more than 35 elders showed signs of abuse, and a large percentage of them were later confirmed to be victims. Changes in housing or living situations were made for several of them.
“It’s difficult to identify and measure appropriate outcomes for elder abuse victims, because each patient may have different care goals,” said Rosen, “but we are working on making a case that detection of elder abuse and intervention in the ER will improve the patients’ lives. We also hope to show that it will save money, because when an elder is in a safe place, expensive, frequent trips to the ER may no longer be needed.”
The team’s ultimate goal is to optimize acute care for these vulnerable victims and ensure their safety. They plan to work at continually tweaking VEPT to improve the program and to connect to emergency medical, law enforcement and criminal justice services. Eventually, they hope to help other emergency departments set up similar programs.

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

Insurers Are Still Denying Treatments for Pre-Existing Conditions

Patients with chronic illness are often forced to jump through hoops to get drugs they need.
Opinion / Commentary – Wall Street Journal
By Craig Blinderman  Aug. 22, 2017 6:25 p.m. ET – Dr. Blinderman is an associate professor of medicine and the director of the Adult Palliative Care Service at Columbia University Medical Center.

One of the principal achievements of the Affordable Care Act was its prohibition on denying insurance coverage to patients with pre-existing conditions. Under the ACA, insurance companies must sell polices to people with chronic diseases and charge the same premiums paid by healthy people.
But patients with pre-existing conditions in fact are being denied coverage when their insurance plans don’t allow for medically recommended treatments or place significant obstacles in the way of getting them. Many plans impose “utilization management” rules restricting access to drugs by requiring prior authorization, quantity limits and so-called step therapy—making patients try a cheaper drug before taking a “step” up to a more expensive treatment.
While such restrictions generally don’t pose significant harms to patients whose conditions aren’t life-threatening, those with a serious illness like cancer or advanced dementia risk being denied treatments that are necessary for the relief of pain and other distressing symptoms.
Over the past 10 years caring for seriously ill patients, I have noticed a marked increase in demands for prior authorizations by insurance companies and other third-party payers before granting approval for certain medications, treatments or procedures. In 2006, according to a Kaiser Family Foundation study, 8% of brand-name medications covered under Medicare Part D required a prior authorization and 18% were subject to some form of utilization management. In 2013, those rates had jumped to 21% and 35%, respectively.
Utilization-management policies don’t actually reduce costs or improve patient outcomes. Time wasted by doctors and their staffs pursuing prior authorizations costs as much as $31 billion in lost productivity annually. A review of the literature suggests that any cost savings due to step therapy or formulary restrictions—only allowing the use of medications on a pre-determined list—are offset by resulting increases in emergency-room visits and hospitalizations. Researchers have found a negative correlation between formulary restrictions and health-care outcomes.
I have seen firsthand how patients suffer when recommended treatments for pain and other distressing symptoms are denied or delayed. One of my patients is a 64-year-old cancer survivor who developed a chronic pain syndrome following multiple surgeries. His insurance company required prior authorization and imposed a monthly quantity limit on the only safe, effective pain medication that he could take without side effects. The delay in getting the proper quantity of medicine led him to experience opioid withdrawal, increased pain, and loss of functioning.
Another patient was denied a prescription for a strong opioid after surgery on a fractured bone related to advanced cancer. I had deemed the medication necessary for her worsening pain. Her insurer rejected the request because she had previously filled a prescription and reached her monthly “quantity limit.”
While reducing health-care costs is essential, insurance-imposed cost-saving measures such as blanket requirements for prior authorizations do more harm than good. Perhaps a special exception should be carved out of the ACA for those with serious illnesses like cancer. Insurance plans, including Medicaid and Medicare, could enact a “preauthorized trial period” for all medications, dosages and quantities deemed necessary by a doctor for the management of severe pain or other debilitating symptoms. Following this trial period, physicians could be asked to justify continuation of the therapy.
Doing this would relieve patient suffering due to delays or disruptions in the amelioration of symptoms, reducing health-care costs in the process. More than half of all U.S. health-care spending goes toward care for the chronically ill and debilitated. Outpatient palliative-care programs reduce costs and unnecessary hospitalizations, improve symptom control and quality of life, and may even improve survival. When patients are denied coverage or experience significant treatment delays, these benefits are unlikely to be realized.
Medicine is about caring for the patient. Health insurance is about providing timely access to care. When health insurance limits treatments for seriously ill patients, it harms those who need care most.

Nerve fibers regenerated with molecular mix

Ana Sandoiu, Medical News Today    August 17, 2017

Scientists may have found a way to regrow axons – a crucial part of a neuron also known as a nerve fiber – after injury. The findings may help patients with spinal cord injury, stroke, or other neurodegenerative conditions recover their motor skills.
A team of researchers at Boston Children’s Hospital in Massachusetts have developed a “recipe” for a mixture of molecules and tested its therapeutic potential in mice with spinal cord injury (SCI) or stroke.
Stroke is the leading cause of paralysis in the United States, accounting for over a third of the 5.4 million people who are living with different forms of paralysis.
SCI comes a close second, as 27 percent of all cases of paralysis are caused by SCI, and 17,000 new cases of SCI occur every year.
After a patient has an SCI or a stroke, the axons in the brain’s cortex and along the spinal cord become damaged. A neuron is comprised of a cell body and two extensions: the dendrite and the axon, which looks like a long chord that sends signals from the main cell.
In the new study, the researchers – led by Zhigang He, Ph.D., of Boston Children’s Hospital and Harvard Medical School – administered a molecule mix to mice in the hope that it would restore their axons. The findings were published in the journal Neuron.
Testing the molecular mix in mice
He and colleagues started out from a previous study they had collaborated on with scientists at Harvard.
In this research, they found that combining a growth hormone secreted by the liver called “insulin-like growth factor 1” (IGF1) with a protein called osteopontin (OPN) improved vision in optically injured rodents by regenerating the axons of their optical nerve.
OPN has been shown to be involved in the inflammation and degeneration of the nervous system, playing a key role in neurodegenerative diseases such as multiple sclerosis (MS), Parkinson’s disease, and Alzheimer’s disease.
In the mouse model of SCI, He and team examined two groups of mice: a group that received the molecular mix after having the injury, and a control group that did not.
In the former group, the researchers injected the mice with the mix of IGF1 and OPN 1 day after the rodents had the SCI.
In the stroke model, the treated mice received the mix 3 days after injury.
The researchers tested the mice’s motor abilities, including their fine motor skills, by examining their ability to walk on a horizontal ladder with unevenly spaced rungs.
Treated mice recover fine motor skills
The researchers found that, compared with the control group, the treated mice showed drastic improvement in their fine motor skills.
In the untreated control group, motor function was gradually and partially restored after injury due to the natural regrowth of axons.
The mice regained a lot of their motor function, but remained significantly impaired in their fine motor skills, as revealed by the irregular ladder test.
Treated mice, however, made far fewer errors on this test; in fact, at week 12 after the injury, the mice made errors only 46 percent of the time. By contrast, the control group had an error rate of 70 percent.
Next, the researchers wanted to test if adding 4-aminopyridine-3-methanol – a potassium channel blocker known to improve axonal conduction in patients with MS – would improve the results even further.
After adding this third ingredient, the error rates in treated mice further decreased to 30 percent. Healthy mice made mistakes 20 percent of the time, so the treated mice fared very well by comparison.
“In our lab, for the first time, we have a treatment that allowed the spinal cord injury and the stroke model to regain functional recovery.” – Zhigang He, Ph.D.
To see whether these results were due to a “resprouting” of axons, the researchers also examined spinal cord sections of the mice.
“We saw what we expected – axon sprouting in [the] spinal cord,” says He. “But we also found something unexpected – increased axon sprouting in the subcortical area.”
He and colleagues performed further tests where they genetically engineered mice to lack axons in the corticospinal tract (CST) in the spinal cord.
Further assessments of the mice’s fine motor skills revealed that improvements in post-injury error rates decreased significantly in these mice that lacked CST axons.
Therefore, this suggests the recovery achieved by the therapeutic mix did not depend so much on the axons’ regrowth in subcortical areas, but on the regeneration of axons in the CST.
So, the “functional outcomes” of the subcortical axons that were found to have resprouted “remain to be tested,” the lead investigator says.
Ultimately, as a next step stemming from this research, He and colleagues plan to test the molecular mix in human clinical trials.

Does laser therapy for knee pain work?

By Zawn Villines   Last updated Wed 16 Aug 2017 – Medical News Today

Laser therapy is an alternative treatment for some types of pain, such as that often associated with the knee. Research on laser therapy is preliminary, and most insurers still consider it to be experimental. However, some studies show it can alleviate pain, including knee pain.
Laser therapy is also known as cold laser therapy, class III laser therapy, or low-level laser therapy (LLLT). Some early studies have shown lasers might help wounds heal. If true, this suggests they could help the body to repair tissue damage caused by injuries and arthritis or other diseases. However, the first studies of cold therapy lasers were not controlled clinical studies.
Laser therapy is relatively new, and researchers do not yet know if it has any long-term risks. Most studies have looked at short-term effects, so it is possible that laser therapy could trigger longer-term side effects that have not yet been realized.
Fast facts on laser therapy for knee pain:
 Proponents of laser therapy say it offers both temporary pain relief and long-term healing.
 Supporters of laser therapy suggest it could treat ailments as diverse as arthritis, chronic pain, joint disorders, and even addictions, such as smoking.
 Research on pain in other areas of the body suggests that laser therapy can, as a minimum, offer temporary pain relief.
 Unlike surgical lasers, cold lasers do not heat up the body’s tissues.

What is laser therapy?

Surgical lasers are increasingly common in medicine and cut more precisely than traditional surgical equipment, reducing the risk of injury and helping speed up surgery.
However, these “hot” lasers can be dangerous when incorrectly used. On the other hand, the “cold” lasers used in LLT to treat pain are much weaker than surgical lasers and cannot cut through or burn skin.
Proponents of laser therapy argue that the skin absorbs very little light, allowing a laser to penetrate deeply into tissue. This lets it heal damaged tissue with no side effects. And because the wattage is very low, there is no risk of a burn.

Can laser therapy help knee pain?
Experts are unsure of the answer to this question.
Most research has focused on osteoarthritis and chronic pain. If laser therapy does work, it is unclear how or why. The lasers might improve circulation, support cell health, release endorphins that fight pain, reduce inflammation, or encourage the growth of new, healthy tissue.
Preliminary research is promising. But there is no conclusive proof that cold therapy lasers can treat pain or any underlying medical condition. Many insurers, as well as Medicare and Medicaid, do not cover laser therapy.
What do the clinical studies say?
A 2005 Cochrane review assessed the ability of LLT to reduce the pain of rheumatoid arthritis, a common cause of knee pain. It found evidence for moderate short-term pain relief with few side effects.
A 2009 study compared people with knee pain who received LLT to a group who only thought they were receiving LLT. Compared to the placebo group, those who received laser therapy reported less pain.
Because it is unclear how laser therapy works, it is not known whether the results of these studies can be applied to the knee.
A 2008 study looked at previous randomized, placebo-controlled studies of LLT for treating tennis elbow. The studies included in the analysis did not look at how or why laser therapy reduced pain and did not measure long-term pain relief.
A 2009 analysis looked at previous research on laser therapy for neck pain. The study found significant pain relief, lasting up to 22 weeks. While some people experienced side effects, these effects were no different from those experienced from a placebo.
Why is it so hard to determine if it works?
One of the problems with laser therapy is that different studies look at different wavelengths of light. This makes it difficult to compare one laser to another. Likewise, different manufacturers make different recommendations about treatment frequency and duration.
For laser therapy to become a standard treatment for knee pain, doctors would need to know which wavelength is most effective and at what dosage.
Risks and complications of laser therapy
The lasers used in this type of therapy are cold, so there is little risk of serious side effects. Most studies have found no side effects. When studies do find side effects, they are minor and similar to the side effect of a placebo. As the lasers are cold and less powerful than other medical lasers, it is unlikely that they can cause serious health issues.
Little research has shown that laser therapy offers long-term relief. For people seeking affordable relief, there are often better options, including treating the underlying causes of pain, such as rheumatoid arthritis.
What are the alternatives to laser therapy for knee pain?

Home management strategies, such as rest, ice packs, compression, heat, massage, stretching, exercise, and the use of over-the-counter medications, can all offer temporary relief for minor knee pain.
For chronic or severe knee pain some treatments may offer relief. These include:
 strengthening exercises
 physical therapy
 knee injections, hyaluronic acid supplements and corticosteroids
 arthrocentesis, involving removal of joint fluid through a needle
 prescription non-steroidal anti-inflammatory drugs (NSAIDs)
 arthritis medications, such as biologics, anti-rheumatics, corticosteroids, and pain relievers
 alternative treatments, such as acupuncture and chiropractic care
 knee surgery
Laser therapy can work alongside these treatments, so trying laser therapy does not mean having to forgo other options.

CVS Moves Deeper Into Doctors’ Turf

Company plans to use pharmacists, clinics to help manage diabetes, other chronic diseases
By Sharon Terlep  The Wall Street Journal   Aug. 8, 2017 3:56 p.m. ET

CVS Health Corp., hit by slower store sales and the defection of some big insurance providers, is moving ever more onto doctors’ turf in a bid to win back business.
The company said Tuesday that it intends to expand a program in which it marshals pharmacists, hundreds of on-site medical clinics and its vast data network to help people manage chronic diseases including asthma and high blood pressure.
It is an extension of a test program launched earlier this year to help improve the health of people with diabetes through close monitoring of glucose levels, medication adherence and lifestyle habits.
In taking on chronic disease, one of health care’s most vexing and costly problems, CVS sees an opportunity to wrest back business from competitors in the pharmacy-benefits sector.
CVS last year lost contracts from Prime Therapeutics, which manages pharmacy benefits for some Blue Cross and Blue Shield plans, and Tricare, a U.S. Defense Department health-care program, to Walgreens Boots Alliance Inc. At the time, the company said the lost deals could cost it 40 million prescriptions this year.
Prescription volumes were flat for the most recent quarter, the company said Tuesday, largely because of the loss of contracts to Walgreens. Overall, profit and revenue rose as an increase in pharmacy services offset declines in retail sales and pharmacy same-store sales. Pharmacy services, such as managing drug claims for health plans, accounted for $32.3 billion of the company’s $45.7 billion in second-quarter revenue.
The CVS program to manage chronic disease aims to bring down costs both for patients and their insurance providers, the company said. In order for people to participate, they must belong to a health plan that has a contract with CVS’s pharmacy-benefit business.
Drugstore chains have long deployed resources to help patients combat chronic diseases. Walgreens has a program with Express Scripts Holding Co., the largest U.S. administrator of prescription-drug benefits, to improve medication adherence for people with diabetes. But the CVS program is more extensive and unusual in that it aims to lure back insurers to its pharmacy-benefits management services.
“We tell our [insurance] clients that these members have to be in one of our channels to get the value of these programs,” said Jonathan Roberts, CVS’s chief operating officer. “There will be a share shift that comes as clients adopt these programs, and we demonstrate our ability to lower overall health-care cost.”
As store sales have slowed for both CVS and Walgreens, which combined filled more than three billion U.S. prescriptions in 2016, the two companies have worked to beef up their prescription-drug businesses. The already pitched competition between the pharmacy giants could intensify as new rivals look to enter the fray. Earlier this year, Inc. was reported to have hired a team to develop a strategy for breaking into the pharmacy market. Amazon declined to comment.
Given that treatment of chronic diseases comprise roughly 70% of the $4 trillion spent annually in the U.S. on health care, any effort to combat the problem is welcome, said Mark Fendrick, a University of Michigan physician and professor focusing on chronic-disease management.
Getting patients to take their medications properly and consistently is a major problem in managing the conditions, said Dr. Fendrick, and one legions of experts over the years have failed to solve.
“There is a lot upside given the low adherence, so it comes as no surprise to see any large pharmacy to get more actively involved in providing care,” Dr. Fendrick said.
One concern of medical professionals is that providing medical services outside a patient’s regular network of doctors could lead to gaps in their records. CVS said it shares the results with patients’ health providers that use the same record-keeping network, provided the patient consents.
In addition to diabetes, CVS will roll out programs over the next two years to manage asthma, hypertension, hypercholesterolemia, or high cholesterol, and depression.
People in the diabetes program get one-on-one support and coaching by phone and at CVS pharmacies and MinuteClinics, generally staffed by physician assistants and nurse practitioners, for no out-of-pocket cost. They also receive a glucometer that measures and shares blood glucose levels digitally to CVS, which can then help head off complications or intervene when issues arise.


When Sports Injuries Lead to Arthritis in Joints

By JANE E. BRODY     AUG. 14, 2017      NYTIMES

When a physically active person like me injures a joint, especially one as crucial as a knee or ankle, one of the first thoughts, if not the first thought, is likely to be “How fast can I get back to my usual activities?”
That kind of thinking, however, could set the stage for a painful chronic problem years later: post-traumatic osteoarthritis.
In the rush to get back in the game, whether as part of a team or elite sport or simply a cherished recreational activity like jogging or tennis, it is tempting to short-circuit the rehabilitation needed to allow the joint to heal fully. But adequate recovery, including rehab measures aimed at strengthening structures that support the injured joint, is critical to maximize its stability, reduce the risk of reinjury and head off irreparable joint damage.
And you don’t have to be a senior citizen to pay the price of failing to build up the tissues that help protect that joint. Studies have shown that when an adolescent or young adult sustains a knee injury, for example, X-ray evidence of arthritis is often apparent within a decade.
As a team of orthopedists and rehabilitation specialists from the University of Iowa explained, “Recent research suggests that acute joint damage that occurs at the time of an injury initiates a sequence of events that can lead to progressive articular surface damage.” That means deterioration of the surface of the bone itself and the connecting tissues that cushion and stabilize bones of a joint like the knee, which is what arthritis is all about.
Osteoarthritis afflicts some 27 million Americans, and that number will certainly grow with the increase in obesity, the current emphasis on lifelong physical activity and the aging of the population. It is a degenerative joint disease that occurs when the protective cartilage on the ends of bones and often the surface of the bones themselves wear down, causing pain, stiffness, instability and disability that can interfere with work and mobility and diminish quality of life.
The Iowa team noted that arthritis will eventually develop in more than 40 percent of people who seriously injure the ligaments (the stabilizing bands that connect bones to one another); the meniscus (the crescent-shaped cartilage that cushions the knee and certain other joints), or the articular surface of a joint. People with a history of trauma to the knee, for example, are three to six times more likely to develop arthritis in that knee. Even without an acute injury, highly repetitive impact on a joint can damage the articular cartilage.
This may help to explain why I ended up with bone-on-bone arthritis and had to replace both knees at age 63. I’d sustained three ligament injuries (while skiing) and after years of running and singles tennis, the meniscus in both knees had shredded. Although I did the recommended physical therapy after each injury, I now know that I was not sufficiently diligent about maintaining the strength and flexibility of the supporting muscles and other tissues that might have better protected my knees for years longer.
Recognizing how common a scenario this is, a prestigious group of athletic trainers has issued a call for a more aggressive approach to both preventing and managing post-traumatic arthritis among physically active people. Although athletic trainers most often treat team players and elite athletes, they also work at physical therapy and rehab clinics where they often see joint damage among recreational athletes like me.
They pointed out in a consensus statement in the Journal of Athletic Training that arthritis should no longer be considered a disease that affects only the elderly.
“Increasing evidence demonstrates that young and middle-aged adults are suffering from osteoarthritis as well,” the statement said. “More than half of adults with symptomatic knee osteoarthritis are younger than 65.”
In fact, as Joseph M. Hart, an athletic trainer who conducts clinical research at the University of Virginia, and his colleagues wrote in the journal, “A 17-year-old athlete who tears her anterior cruciate ligament could develop osteoarthritis before she turns 30, potentially leading to chronic pain and disability.” Damage to this ligament, in the center of the knee, is the most common injury among young athletes, especially girls, they wrote.
Jeffrey B. Driban, an athletic trainer at Tufts Medical Center in Boston, said that one person in three who injures the anterior cruciate ligament “will have X-ray evidence of osteoarthritis within 10 years” whether or not the injury is repaired surgically.
Dr. Driban and co-authors pointed out that some sports – soccer, elite-level long-distance running, competitive weight lifting and wrestling – are associated with a higher risk of knee injuries.
A person’s risk of injury can be reduced by having deficits in muscle strength, balance and stability evaluated and treated, Dr. Hart said in an interview. However, he added, “not all injuries can be prevented, and unless the initial injury is properly treated, it can lead to additional injuries to the same joint or other joints,” increasing the chance that arthritis will develop early in life.
Dr. Driban said in an interview that sports participants who sustain a knee injury can minimize the risk of reinjury and arthritis by “not rushing back into activity or trying to play through pain. They must strengthen the muscles that support the joint – the quads, hamstrings and hip muscles. It’s important to think about the entire lower extremity, not just the knee.”
Following an injury, an athletic trainer, rehabilitation specialist or physical therapist who specializes in orthopedics can evaluate a person’s muscle strength, endurance, balance and movement quality, then guide recovery with a structured rehab program that is maintained for six to nine months, Dr. Hart said.
It is also important to continue to pursue an active lifestyle, said Abby C. Thomas of the University of North Carolina at Charlotte. “You may have to modify the activities you do, but you have to stay active to maintain strength and cardiovascular fitness without putting repetitive stress on a joint that’s already injured. If your knee hurts and you can’t run, maybe get on a bike or swim,” activities that place less stress on the knees.
“Don’t sit around on the couch because running hurts,” Dr. Thomas said. “Try walking, or something different, but don’t give up on physical activity.”
Lifelong activity is also important to prevent weight gain, since every extra pound places disproportionate stress on the knees. All the authors emphasized that pursuing a healthy lifestyle is crucial for everyone, not just elite athletes and those who play on school teams.

We Need to Talk Some More About Your Dirty Sponges


A kitchen sponge is not your enemy. But it can be very dirty. Last week, scientists published a study revealing how densely packed your dirty kitchen sponge is with microscopic bacteria. After I wrote an article about their work, readers flooded my inbox with good questions, so I asked around for some answers.
First, let’s examine what the study did and didn’t do.
The study was designed to establish improved measurements of the bacterial populations that live inside this common household item. Previous measurements had mainly looked at those from sponges dirtied in the lab, growing the bacteria in a petri dish. But because not all bacteria will grow in that medium, their numbers may have been underestimated, said Markus Egert, the microbiologist at the University of Furtwangen in Germany who led the study.
“Our study was mainly thought to create awareness, and not fear,” Dr. Egert wrote in a follow-up email.
But what they found alarmed many readers. Although not designed to evaluate disinfection methods, the researchers collected additional data from the sponge donors (a sample of 14 sponges, which the researchers concede was limited). And to their surprise, sponges regularly cleaned in soapy water or the microwave actually harbored more of a bacteria called Moraxella osloensis. This bacteria is generally common and harmless, but it can cause infections in people with compromised immune systems.
Nonetheless, Dr. Egert suggested that in most cases it may be best to throw away your sponge when it starts to stink — a sign that the nasty bacteria may be there — even if it may not harm you. This decision to toss, said Dr. Egert, means balancing hygiene and sterility, thriftiness and a sustainable environment. The United States Department of Agriculture also suggests buying new sponges frequently, as they are “difficult to clean.”
“You should not become hysteric and afraid of your kitchen sponge now,” said Dr. Egert in our original interview. Even sterile environments can make a person ill, he added. “But if you’re already ill or have ill people at home, you should be more careful.”
And that brings us to talking about risk, which the study was not designed to assess.
Kitchens are hot spots for cross-contamination, and immune systems differ. You could just as easily contract an illness from poorly prepared food or your cellphone as you could from a dirty sponge, many experts say. And two bodies’ responses to the same pathogen can differ, just like a pothole might damage one car but not another, said Kevin Sauer of Kansas State University, who has studied cross-contamination in the kitchen.
But if you’re still worried, here are three tips from Solveig Langsrud, a microbiologist at Nofima, an applied research institution in Norway, who has examined how different hygiene procedures can reduce bacterial contamination in kitchens.
Don’t feed your sponge with dangerous bacteria
Don’t use your sponge to scrub off chunky food debris or wipe up fresh meat juices, dirt from fruits and veggies, unpasteurized milk stuff, vomit or your pet’s droppings. Just use a paper towel, cleanser or running water. Keep sick people away from food preparation areas. (And for those who asked, a vegan kitchen full of raw vegetables is not immune.)
To avoid cross-contamination, wash your hands (properly) and give different sponges their own jobs — like cleaning only your counter, floor or dishes. A proper handwashing means removing jewelry and using soapy water for 20 seconds before drying with a clean towel, said Argyris Magoulas, an information specialist at the Office of Public Affairs and Consumer Education at the U.S.D.A. Food Safety and Inspection Service.
Keep your sponge clean
Dr. Langsrud says that you should wash your sponge after each use, which doesn’t quite jibe with Dr. Egert’s study. But Dr. Egert doesn’t think his donors gave their sponges a correct washing. With some effort, you can disinfect your sponges and get rid of most of their bacteria, although this may not be practical for many of us.
In a 2008 study, Manan Sharma, a microbiologist who studies foodborne pathogens with the U.S.D.A., and his colleagues soaked sponges in ground beef at room temperature for two days to get them extra bacteria-y and then compared common cleaning methods. He found that microwaving and running them through the dishwasher were the most effective killers of some bacteria, mold and yeast.
But there were caveats: A synthetic, metallic or dry sponge can catch fire in the microwave. Microwaves and dishwasher models can vary — you must watch temperatures. Too little heat, time or steam can put your sponge in what Mr. Magoulas calls “the danger zone,” a place where bacteria proliferate. Also make sure your sponge is wet — the steam kills many microbes, experts say.
Dr. Langsrud says drying is also is “a simple, cheap, environmentally friendly and effective way to keep bacterial numbers down.” That’s because moisture-loving bacteria can’t multiply on a dry sponge — for the most part — which brings us to Dr. Langsrud’s final piece of advice and our original conundrum.
Don’t be too attached to your sponge
Even with prevention, washing and drying, some bacteria that live in kitchens can accumulate in the sponge, Dr. Langsrud said. “These bacteria are tolerable to drying and protect themselves in food debris and a self-produced slime,” she said. “They will be impossible to fight.”
She agrees with Dr. Egert: Dispose of sponges at least once a week, or when they smell bad. And if someone is sick in your house, like with cancer, she says to throw away sponges daily. Reuse disinfected sponges in less hygiene-sensitive spots if you must.
This all may make you wonder if you even need a sponge, if some are better than others and if alternatives exist.
Plenty of companies offer solutions — like bacteria-killing baths for sponges, water-repellent surfaces or antimicrobial materials. But without peer-reviewed scientific studies, it’s difficult to evaluate their effectiveness. Also, consider instead brushes, paper towels and washcloths (which are washed more often and used in restaurants).
“Tools that soak less water, dry faster, have smaller inner surfaces might indeed be better for regular cleaning,” Dr. Egert wrote in a follow-up email.
Dr. Sauer says the problem with sponges is that they’re easy to ignore. They inhabit the sink. They stay wet. They get nasty. But can you really blame them? “A lot of us have been brought up to grab that sponge because it takes care of the surface, cleaning what we see,” he said. “I don’t think sponges are the enemy, but they provide a great medium to grow bacteria.”

Stroke Risk Declining in Men but Not Women


The incidence of stroke has declined in recent years, but only in men.
Researchers studied stroke incidence in four periods from 1993 to 2010 in five counties in Ohio and Kentucky. There were 7,710 strokes all together, 57.2 percent of them in women.
After adjusting for age and race, they found that stroke incidence in men had decreased to 192 per hundred thousand men in 2010, down from 263 in 1993–94. But for women the incidence was 198 per hundred thousand in 2010, down from 217 in 1993–94, a statistically insignificant change. The study is in Neurology.
Most of the difference was in ischemic stroke, the most common cause, resulting from a blocked blood vessel supplying blood to the brain.
No one knows why there has been no improvement in women, but the lead author, Dr. Tracy E. Madsen, an assistant professor of emergency medicine at Brown, said that some risk factors have a stronger effect in women than in men. Risk factors for stroke include high blood pressure, heart disease, diabetes and smoking.
“Maybe we’re not controlling risk factors to the same extent in women. Or maybe there’s a biological difference in the way these risk factors cause strokes in men versus women.”
In any case, Dr. Madsen said, “It’s important for women to know they are at risk. Stroke has been considered a male disease, but we know that it is very prevalent in women and has a high risk of disability and death.”