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Objective: Do the 3.5 million US veterans, who primarily utilize private healthcare, have similar bum pit exposure and disease compared to the VA Bum Pit registry? Methods: This is an online volunteer survey of Gulf War and Post-9/11 veterans. Results: Bum pit exposure had significantly higher odds of extremity numbness, aching pain and burning, asthma, chronic obstructive pulmonary disease, interstitial lung disease, constrictive bronchiolitis, pleuritis, and pulmonary fibrosis. Chi-square did not reveal a difference in bum pit exposure and cancer diagnoses. Conclusions: These data demonstrate increased risk of neurological symptoms associated with bum pit exposure, which are not covered in the 2022 federal Promise to Address Comprehensive Toxics Act. Additional data will allow for the continued review and consideration for future medical benefits. [ABSTRACT FROM AUTHOR]

The use of the extremity tourniquet in military environments has reduced preventable deaths due to exsanguinating hemorrhage, leading to increased use in civilian settings. However, the outcomes of contemporary prehospital tourniquet use in civilian settings are not well-described nationally. The objective of this study was to describe the characteristics and outcomes following prehospital tourniquet use by emergency medical services (EMS) in the United States. All trauma activations reported to the National EMS Information System 2019 (NEMSIS) were included. Patients who had ≥1 tourniquet applied were identified. Descriptive analyses were used to compare characteristics between tourniquet and no-tourniquet cohorts. Coarsened exact matching was performed to generate a k2k match (on age, sex, lowest-systolic blood pressure, initial patient acuity, provider's initial impression, injury mechanism, and presence of upper/lower extremity injuries) and used to compare outcomes. Trauma patients who may have potentially benefited from tourniquet application (extremity injury, shock index ≥1 and no documented tourniquet application) were identified. A total of 7,161 tourniquets were applied among 4,571,379 trauma activations (1.6/1000 activations). Patients in the tourniquet cohort were younger (40 ± 18 vs 52 ± 26 mean ± SD years), more hypotensive (16.1% vs. 2.5%) and had higher initial acuity (65.0% critical/emergent vs. 20.6%) [p < 0.01 for all]. A total of 7,074 patients in the tourniquet cohort were matched with 7,074 patients in the non-tourniquet cohort. Post-match analysis revealed that the patients in tourniquet cohort had a higher final acuity (80.8% vs. 75.0%, p < 0.01), lower scene-time (15.4 ± 13.6 vs. 17.0 ± 14.2 mean ± SD minutes, p < 0.01), and higher survival-to-hospital (83.6% vs. 75.1%, p < 0.01). A total of 141,471 trauma patients who may have potentially benefited from tourniquet application were identified. Prehospital tourniquet use by EMS in the United States is associated with lower scene-time and improved survivability to hospital. Results indicate that patients might benefit from wider tourniquet use in the civilian prehospital setting. [ABSTRACT FROM AUTHOR]

To explore indicators that predict whether patients with extremity pain have a spinal or extremity source of pain. The data were from a prospective cohort study (n = 369). Potential indicators were gathered from a typical Mechanical Diagnosis and Therapy (MDT) history and examination. A stepwise logistic regression with a backward elimination was performed to determine which indicators predict classification into spinal or extremity source groups. A Receiver Operating Characteristic (ROC) curve was constructed to examine the number of significant indicators that could predict group classification. Five indicators were identified to predict group classification. Classification into the spinal group was associated with the presence of paresthesia [odds ratio (OR) 1.984], change in symptoms with sitting/neck or trunk flexion/turning neck/when still (OR 2.642), change in symptoms with posture change (OR 3.956), restrictions in spinal movements (OR 2.633), and no restrictions in extremity movements (OR 2.241). The optimal number of indicators for classification was two (sensitivity = 0.638, specificity = 0.807). This study provides guidance on clinical indicators that predict the source of symptoms for isolated extremity pain. The clinical indicators will allow clinicians to supplement their decision-making process in regard to spinal and extremity differentiation so as to appropriately target their examinations and interventions. [ABSTRACT FROM AUTHOR]

To identify and appraise the existing clinical practice guidelines, consensus statements and Cochrane systematic reviews for the management of adult and paediatric focal spasticity to generate a single synthesized guideline. Systematic review of 12 electronic databases. Clinical practice guidelines, consensus statements and Cochrane systematic reviews for focal spasticity in adults and children. Included studies were appraised according to the AGREE II criteria. A total of 25 papers were included in this review, comprising 12 clinical practice guidelines, nine consensus statements and four Cochrane systematic reviews. The areas most strongly endorsed were: (1) management to be provided by a multi-disciplinary team, (2) therapy should be goal-directed, (3) goals to be developed in conjunction with the patient and family, and (4) importance of follow-up evaluations. There was a greater focus on activity outcomes and classification in the paediatric papers. The guidelines varied considerably in their quality, with AGREE II scores ranging from 52.8 to 97.1%. This systematic review has synthesized the key elements regarding principles of focal spasticity management, outcome measures, physical interventions and educational recommendations into a single, readily applied guideline available for clinical use. Despite considerable variability in the quality of the guidelines, several strong themes emerged. Focal spasticity management should be multi-disciplinary, patient-centred and goal-directed. Routine measurement of impairment and activity are strongly endorsed. Botulinum toxin A injection should only be provided as part of an integrated approach to focal spasticity management. [ABSTRACT FROM AUTHOR]

Context: Although randomized controlled trials indicate that the Mulligan Concept (MC) of mobilization with movement can improve pain-free grip strength and pressure pain threshold in patients with lateral epicondylalgia of the elbow, improve ankle dorsiflexion in patients with subacute ankle sprains, and decrease the signs and symptoms of patients with cervicogenic headache, little is known about the clinical application, use, and profile of certified Mulligan practitioners (CMPs) in America. Objective: To better understand the use and value of applying the MC philosophy in clinical-care environments from the perspective of American CMPs while establishing a clinical profile of a CMP. Design: Quantitative descriptive design. Setting: Online survey instrument. Participants: American CMPs. Data Collection and Analysis: Online survey instrument. Results: CMPs use the MC to treat a broad spectrum of spinal and peripheral clinical pathologies in primarily outpatient clinics with an active and athletic population. American CMPs also find value in the MC. Conclusions: American CMPs continue to use and find value in the MC intervention strategy to treat a broad spectrum of spinal and peripheral conditions in their clinical practices. [ABSTRACT FROM AUTHOR]

Background: Fractures in late life are highly consequential for health, services use, and spending. Little is known about trends in extremity fracture hospitalizations among older adults in the United States. Design Retrospective longitudinal cohort study. Setting: The 2003–2017 National Inpatient Sample (NIS), a representative sample of U.S. community hospitals. Participants: Hospitalized adults aged 65 and older with a diagnosis of upper or lower extremity fracture. Measurements Incidence of extremity fracture hospitalization and mortality, using NIS discharge and trend weights, and population denominators derived from the U.S. Census Bureau. Incidence was reported separately for men and women by age, fracture diagnosis, and injury mechanism. Weighted linear regression was used to test for significant trends over time. Results: Incidence of extremity fracture hospitalizations declined in both women (15.7%, p trend < 0.001) and men (3.2%, p trend < 0.001) between 2003 and 2017. This trend was primarily attributed to a decline in low energy femur fractures which accounted for 65% of all fracture hospitalizations. Among older adults with an extremity fracture hospitalization, mortality declined from 5.1% in 2003 to 3.3% in 2017 in men, and from 2.6% to 1.9% in women (p trend < 0.001). High energy fractures were due to falls (53%), motor vehicle accidents (34%), and other high impact injuries (13%). Overall, 12% of extremity fracture hospitalizations were attributed to high‐energy injuries: increases were observed among men ages 65–74 (20%; p trend < 0.001) and 75–84 (10%; p trend = 0.013), but not among women of any age. Conclusion: Observed declines in the incidence of extremity fracture hospitalizations and related mortality are encouraging. However, increasing incidence of fracture hospitalization from high energy injuries among men suggests that older adults with complex injuries will be seen with more prevalence in the future. [ABSTRACT FROM AUTHOR]

Background: Historically, amputation was the primary surgical treatment for osteosarcoma of the extremities; however, with advancements in surgical techniques and chemotherapies limb salvage has replaced amputation as the dominant treatment paradigm. This study assessed the type of surgical resection chosen for osteosarcoma patients in the twenty-first century.Methods: Utilizing the largest registry of primary osteosarcoma, the National Cancer Database (NCDB), we retrospectively analyzed patients with high grade osteosarcoma of the extremities from 2004 through 2015. Differences between patients undergoing amputation and patients undergoing limb salvage are described. Unadjusted five-year overall survival between patients who received limb salvage and amputation was assessed utilizing Kaplan Meier curves. A multivariate Cox proportional hazard model and propensity matched analysis was used to determine the variables independently correlated with survival.Results: From a total of 2442 patients, 1855 underwent limb salvage and 587 underwent amputation. Patients undergoing amputation were more likely to be older, male, uninsured, and live in zip codes associated with lower income. Patients undergoing amputation were also more likely to have larger tumors, more comorbid conditions, and metastatic disease at presentation. After controlling for confounders, limb salvage was associated with a significant survival benefit over amputation (HR: 0.70; p < 0.001). Although this may well reflect underlying biases impacting choice of treatment, this survival benefit remained significant after propensity matched analysis of all significantly different independent variables (HR: 0.71; p < 0.01).Conclusion: Among patients in the NCDB, amputation for osteosarcoma is associated with advanced age, advanced stage, larger tumors, greater comorbidities, and lower income. Limb salvage is associated with a significant survival benefit, even when controlling for significant confounding variables and differences between cohorts. [ABSTRACT FROM AUTHOR]

Background: Several recently published population-based studies have highlighted the association between insurance status and survival in patients with various cancers such as breast, head and neck, testicular, and lymphoma [22, 24, 38, 41]. Generally, these studies demonstrate that uninsured patients or those with Medicaid insurance had poorer survival than did those who had non-Medicaid insurance. However, this discrepancy has not been studied in patients with primary bone and extremity soft-tissue sarcomas, a unique oncological population that typically presents late in the disease course and often requires referral and complex treatment at tertiary care centers-issues that health insurance coverage disparities could aggravate.Questions/purposes: (1) What is the relationship between insurance status and cause-specific mortality? (2) What is the relationship between insurance status and the prevalence of distant metastases? (3) What is the relationship between insurance status and the proportion of limb salvage surgery versus amputation?Methods: The Surveillance, Epidemiology, and End Results database (SEER) was used to identify a total of 12,008 patients: 4257 patients with primary bone sarcomas and 7751 patients with extremity soft-tissue sarcomas, who were diagnosed and treated between 2007 and 2014. Patients were categorized into one of three insurance groups: insured with non-Medicaid insurance, insured with Medicaid, and uninsured. Patients without information available regarding insurance status were excluded (2.7% [113 patients] with primary bone sarcomas and 3.1% [243 patients] with extremity soft-tissue sarcomas.) The association between insurance status and survival was assessed using a Cox proportional hazards regression analysis adjusted for patient age, sex, race, ethnicity, extent of disease (lymph node and metastatic involvement), tumor grade, tumor size, histology, and primary tumor site.Results: Patients with primary bone sarcomas with Medicaid insurance had reduced disease-specific survival than did patients with non-Medicaid insurance (hazard ratio 1.3 [95% confidence interval 1.1 to 1.6]; p = 0.003). Patients with extremity soft-tissue sarcomas with Medicaid insurance also had reduced disease-specific survival compared with those with non-Medicaid insurance (HR 1.2 [95% CI 1.0 to 1.5]; p = 0.019). Patients with primary bone sarcomas (relative risk 1.8 [95% CI 1.3 to 2.4]; p < 0.001) and extremity soft-tissue sarcomas (RR 2.4 [95% CI 1.9 to 3.1]; p < 0.001) who had Medicaid insurance were more likely to have distant metastases at the time of diagnosis than those with non-Medicaid insurance. Patients with primary bone sarcomas (RR 1.8 [95% CI 1.4 to 2.1]; p < 0.001), and extremity soft-tissue sarcomas (RR 2.4 [95% CI 1.9 to 3.0]; p < 0.001) that had Medicaid insurance were more likely to undergo amputation than patients with non-Medicaid insurance. Patients with primary bone and extremity soft-tissue sarcomas who were uninsured were not more likely to have distant metastases at the time of diagnosis and did not have a higher proportion of amputation surgery as compared with patients with non-Medicaid insurance. However, uninsured patients with extremity soft-tissue sarcomas still displayed reduction in disease-specific survival (HR 1.6 [95% CI 1.2 to 2.1]; p = 0.001).Conclusions: Disparities manifested by differences in insurance status were correlated with an increased risk of metastasis at the time of diagnosis, reduced likelihood of treatment with limb salvage procedures, and reduced disease-specific survival in patients with primary bone or extremity soft-tissue sarcomas. Although several potentially confounding variables were controlled for, unmeasured confounding played a role in these results. Future studies should seek to identify what factors drive the finding that substandard insurance status is associated with poorer survival after a cancer diagnosis. Candidate variables might include medical comorbidities, treatment delays, time to first presentation to medical care and time to diagnosis, type of treatment received, distance travelled to treatments and transportation barriers, out-of-pocket payment burden, as well as educational and literacy status. These variables are almost certainly associated with socioeconomic deprivation in a vulnerable patient population, and once identified, treatment can become targeted to address these systemic inequities.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Long-term cardiovascular and limb outcomes after revascularization for peripheral artery disease and, in particular, prognosis after post-procedure major adverse limb events (MALE) are not well-studied.Objectives: This study sought to describe outcomes after peripheral revascularization and assess relationships between post-procedure MALE hospitalization and subsequent events.Methods: Patients undergoing peripheral artery revascularization between January 1, 2009, and September 30, 2015, in the Premier Healthcare Database were examined for the co-primary outcomes of interest, composite myocardial infarction (MI) or stroke and composite major amputation or peripheral revascularization. Multivariable adjusted Cox proportional hazards models with post-procedure MALE hospitalization included as a time-dependent covariate were developed to estimate hazard ratios for outcomes.Results: Among 393,017 revascularized patients followed for a median of 2.7 years (interquartile range: 1.3 to 4.4 years), the cumulative incidence of MI or stroke was 9.8% and that of major amputation or peripheral revascularization was 41.9%. A total of 50,750 patients (12.9%) had at least 1 post-procedure MALE hospitalization. In time-dependent covariate adjusted models, post-procedure MALE hospitalization was associated with greater risk of subsequent MI or stroke (hazard ratio: 1.34; 95% confidence interval: 1.28 to 1.40) and major amputation or peripheral revascularization (hazard ratio: 8.13; 95% confidence interval: 7.96 to 8.29). After peripheral revascularization with or without post-procedure MALE hospitalization, risk of limb events increased rapidly post-procedure and more slowly after the first year, whereas cardiac risk increased steadily during follow-up.Conclusions: Revascularized peripheral artery disease patients face earlier limb and later cardiovascular ischemic risk that is heightened among patients with post-procedure MALE hospitalization. Increased provider awareness of these long-term risks may guide efforts to improve post-procedural outcomes. [ABSTRACT FROM AUTHOR]

Introduction: We examined antibiotic management of combat-related extremity wound infections (CEWI) among wounded U.S. military personnel (2009-2012).Methods: Patients were included if they sustained blast injuries, resulting in ≥1 open extremity wound, were admitted to participating U.S. hospitals, developed a CEWI (osteomyelitis or deep soft-tissue infections) within 30 days post-injury, and received ≥3 days of relevant antibiotic (s) for treatment.Results: Among 267 patients, 133 (50%) had only a CEWI, while 134 (50%) had a CEWI plus concomitant non-extremity infection. In the pre-diagnosis period (4-10 days prior to CEWI diagnosis), 95 (36%) patients started a new antibiotic with 28% of patients receiving ≥2 antibiotics. During CEWI diagnosis week (±3 days of diagnosis), 209 (78%) patients started a new antibiotic (71% with ≥2 antibiotics). In the week following diagnosis (4-10 days after CEWI diagnosis), 121 (45%) patients started a new antibiotic with 39% receiving ≥2 antibiotics. Restricting to ±7 days of CEWI diagnosis, patients commonly received two (35%) or three (27%) antibiotics with frequent combinations involving carbapenem, vancomycin, and fluoroquinolones.Conclusions: Substantial variation in antibiotic prescribing patterns related to CEWIs warrants development of combat-related clinical practice guidelines beyond infection prevention, to include strategies to reduce the use of unnecessary antibiotics and improve stewardship. [ABSTRACT FROM AUTHOR]

Background: Children who present to the emergency department (ED) with complaint of fever and new-onset joint or extremity pain can be a diagnostic dilemma for many emergency and consulting physicians.Objectives: The purpose of our study was to identify the etiologies of pediatric fever and extremity pain presenting to a tertiary care pediatric ED and to define factors that were associated with advanced imaging, admission, and surgical intervention.Methods: The electronic medical records of children presenting to our institution's pediatric ED with fever and extremity pain were retrospectively reviewed. Data collected included demographic characteristics, laboratory studies, diagnostic imaging, need for admission, and surgical procedures.Results: The initial ED diagnosis was consistent with the definitive diagnosis 42% of the time. Children with the inability to bear weight on the affected limb were more likely to have a bacterial infection, such as osteomyelitis, septic arthritis, or intramuscular abscess (p = 0.016). An erythrocyte sedimentation rate >36 mm/hour and C-reactive protein levels >60 mg/L were found in children with osteomyelitis or septic arthritis (p = 0.043 and <0.001, respectively). Magnetic resonance imaging was ordered in 63% of children with multiple visits compared to 34% of children with a single visit (p = 0.05).Conclusions: In addition to a thorough history and physical examination, a complete set of laboratory studies and diagnostic imaging is necessary to reach an accurate diagnosis. The inability to bear weight, elevated C-reactive protein levels, and an elevated erythrocyte sedimentation rate are associated with bacterial infection. Magnetic resonance imaging is a useful imaging modality in determining an accurate diagnosis. [ABSTRACT FROM AUTHOR]

Background: The identification of novel rehabilitative impairments that are risk factors for mobility limitations may improve their prevention and treatment among older adults. We tested the hypothesis that impaired rhythmic interlimb ankle and shoulder coordination are risk factors for subsequent mobility limitations among older adults.Methods: We conducted a 1-year prospective cohort study of community-dwelling older adults (N = 99) aged 67 years and older who did not have mobility limitations (Short Physical Performance Battery score > 9) at baseline. Participants performed antiphase coordination of the right and left ankles or shoulders while paced by an auditory metronome. Using multivariable logistic regression, we determined odds ratios (ORs) for mobility limitations at 1-year follow-up as a function of coordination variability and asymmetry.Results: After adjusting for age, sex, body mass index, Mini-Mental State Examination score, number of chronic conditions, and baseline Short Physical Performance Battery score, ORs were significant for developing mobility limitations based on a 1 SD difference in the variability of ankle (OR = 1.88; 95% confidence interval [CI]: 1.16-3.05) and shoulder (OR = 1.96; 95% CI: 1.17-3.29) coordination. ORs were significant for asymmetry of shoulder (OR = 2.11; 95% CI: 1.25-3.57), but not ankle (OR = 0.95; 95% CI: 0.59-1.55) coordination. Similar results were found in unadjusted analyses.Conclusions: The results support our hypothesis that impaired interlimb ankle and shoulder coordination are risk factors for the development of mobility limitations. Future work is needed to further examine the peripheral and central mechanisms underlying this relationship and to test whether enhancing coordination alters mobility limitations. [ABSTRACT FROM AUTHOR]

Background: High loss-to-follow-up rates are a risk in even the most rigorously designed randomized controlled trials (RCTs). Consequently, predicting and preventing loss to follow-up are important methodological considerations. We hypothesized that certain baseline characteristics are associated with a greater likelihood of patients being lost to follow-up. Our primary objective was to determine which baseline characteristics are associated with loss to follow-up within 12 months after an open fracture in adult patients participating in the Fluid Lavage of Open Wounds (FLOW) trial. We also present strategies to reduce loss to follow-up in trauma trials.Methods: Data for this study were derived from the FLOW trial, a funded trial in which payments to clinical sites were tied to participant retention. We conducted a binary logistic regression analysis with loss to follow-up as the dependent variable to determine participant characteristics associated with a higher risk of loss to follow-up.Results: Complete data were available for 2,381 of 2,447 participants. One hundred and sixty-three participants (6.7%) were lost to follow-up. Participants who received treatment in the U.S. were more likely to be lost to follow-up than those who received treatment in other countries (odds ratio [OR] = 3.56, 95% confidence interval [CI]: 2.46 to 5.17, p < 0.001). Male sex (OR = 1.75, 95% CI: 1.15 to 2.67, p = 0.009), current smoking (OR = 1.82, 95% CI: 1.28 to 2.58, p = 0.001), high-risk alcohol consumption (OR = 1.88, 95% CI: 1.16 to 3.05, p = 0.010), and an age of <30 years (OR = 2.16, 95% CI: 1.19 to 3.95, p = 0.012) all significantly increased the odds of a patient being lost to follow-up. Conversely, participants who had sustained polytrauma (OR = 0.52, 95% CI: 0.37 to 0.73, p < 0.001) or had a Gustilo-Anderson type-IIIA, B, or C fracture (OR = 0.60, 95% CI: 0.38 to 0.94, p = 0.024) had lower odds of being lost to follow-up.Conclusions: Using a number of strategies, we were able to reduce the loss-to-follow-up rate to <7%. Males, current smokers, young participants, participants who consumed a high-risk amount of alcohol, and participants in the U.S. were more likely to be lost to follow-up even after these strategies had been employed; therefore, additional strategies should be developed to target these high-risk participants.Clinical Relevance: This study highlights an important need to develop additional strategies to minimize loss to follow-up, including targeted participant-retention strategies. Male sex, an age of <30 years, current smoking, high-risk alcohol consumption, and treatment in a developed country with a predominantly privately funded health-care system increased the likelihood of participants being lost to follow-up. Therefore, strategies should be targeted to these participants. Use of the planning and prevention strategies outlined in the current study can minimize loss to follow-up in orthopaedic trials. [ABSTRACT FROM AUTHOR]

Background: The association between history of keratinocyte carcinoma (KC, also known as nonmelanoma skin cancer) and risk of developing invasive melanoma has not been assessed comprehensively using prospective data.Methods: We followed 91 846 women in the Nurses' Health Study (NHS; 1984-2010), 114 918 women in the NHSII (1989-2011), and 48 946 men in the Health Professionals Follow-up Study (1986-2010) for diagnoses of KC and melanoma biennially. Cox proportional hazards models were used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) of melanoma associated with history of KC, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC). All statistical tests were two-sided.Results: We documented 1949 melanomas, 38 842 BCCs, and 7462 SCCs over 6.4 million person-years of follow-up. After adjustment for other risk factors, a personal history of KC was associated with an increased risk of melanoma (meta-analysis HR = 2.22, 95% CI = 1.73 to 2.85). The association was more apparent among participants with a history of both BCC and SCC (HR = 3.40, 95% CI = 1.60 to 7.19) than among participants with a history of BCC only (HR = 2.20, 95% CI = 1.80 to 2.70) or SCC only (HR = 1.56, 95% CI = 0.98 to 2.46), and there was a strong risk-increasing trend associated with a higher number of reported KCs removed by surgery ( P trend < .001). In women, KC history was more strongly associated with head/neck melanomas (HR = 4.17, 95% CI = 2.77 to 6.27) than with trunk or limb melanomas (both HRs < 2.50, P heterogeneity = .04).Conclusions: Our results provide novel insights for the relationship between KC history and risk of developing melanoma, which may be important for melanoma prevention. [ABSTRACT FROM AUTHOR]

Aims To compare the acute effects of alcohol on set-shifting task performance (relative to sober baseline performance) during ascending and descending limb breath alcohol concentration (BrAC), as well as possible moderation of these effects by baseline individual differences. Design Shifting performance was tested during an initial baseline and a subsequent drinking session, during which participants were assigned randomly to one of three beverage conditions (alcohol, placebo or control) and one of two BrAC limb conditions [ascending and descending (A/D) or descending-only (D-only)]. Setting A human experimental laboratory on the University of Missouri campus in Columbia, MO, USA. Participants A total of 222 moderate-drinking adults (ages 21-30 years) recruited from Columbia, MO and tested between 2010 and 2013. Measurements The outcome measure was performance on set-shifting tasks under the different beverage and limb conditions. Shifting performance assessed at baseline was a key moderator. Findings Although performance improved across sessions, this improvement was reduced in the alcohol compared with no-alcohol groups (post-drink latent mean comparison across groups, all Ps ≤ 0.05), and this effect was more pronounced in individuals with lower pre-drink performance (comparison of pre- to post-drink path coefficients across groups, all Ps ≤ 0.05). In the alcohol group, performance was better on descending compared with ascending limb ( P ≤ 0.001), but descending limb performance did not differ across the A/D and D-only groups. Conclusions Practising tasks before drinking moderates the acute effects of alcohol on the ability to switch between tasks. Greater impairment in shifting ability on descending compared with ascending breath alcohol concentration is not related to task practice. [ABSTRACT FROM AUTHOR]

Background:Tourniquet use by Emergency Medical Services (EMS) can be life saving for severely injured patients. The adoption of this intervention is not well described in civilian settings. This study describes patterns and trends of tourniquet use by civilian EMS and identifies predictors of such use.Methods:A retrospective study of four consecutive releases of the U.S. National Emergency Medical Services Information System (NEMSIS) public research dataset (2011–14) was conducted. Descriptive analysis was performed to compare two groups of EMS activations for injuries with or without tourniquet application. This was followed by multivariate logistic regression to identify predictors of tourniquet use.Results:A total of 2,048 tourniquet applications were documented among all EMS activations for injured patients (N= 10,366,537) yielding a prevalence of 0.2 per 1,000 EMS activations. Tourniquets were mainly applied in young (mean age 44.0 ± 21.1 years) male patients (76.5%) in urban and suburban EMS activations (86.4%) and by advanced life support (ALS) EMS services (81.6%). Most common complaints reported by dispatch for EMS activations with tourniquet use were Traumatic injury (25.3%), Hemorrhage/laceration (23.5%), and Traffic accident (16.8%) with injuries mainly related to Stabbing/Accidental cutting (20.3%), Falls (17.1%), and Motor vehicle traffic accident (11.5%). Upper extremity injuries (39.6%) were more common than Lower extremity injuries (27.3%). The providers’ primary impression was predominantly Traumatic injury (92.8%), and patients’ primary symptoms were mainly Bleeding (50.4%) and Wound (28.7%). All prehospital time intervals except on-scene time interval were significantly shorter in the group with tourniquets compared to the group without tourniquets (p < 0.05). Reported prevalence of tourniquet use by EMS (per 1,000 EMS injury activations) increased from 2011 to 2012 then stabilized over the following years (2012–14). Significant predictors of tourniquet use reported by the provider were identified and included demographic characteristics, EMS agency type, specific complaints, injury cause, injury anatomic location, chief complaint organ system, and primary symptom.Conclusion:Reported tourniquet use by EMS for injured patients in the U.S. is low. Increasing adoption mainly by urban services was noted. Predictors for tourniquet use in civilian trauma were identified. Establishing the effectiveness of this intervention by comparing patient outcomes is needed.Key words:emergency medical services; prehospital; tourniquet; injury; NEMSIS; hemorrhage [ABSTRACT FROM PUBLISHER]

A reprint of an article is presented which was originally appeared in "The Boston Medical and Surgical Journal," on the improper treatment of wounds in some of the U.S. hospitals. Topics discussed include class of injuries over which the cold-water cure has held despotic sway; understanding vital actions, properties, organizations, functions and habits of a tissue or organ in health and disease; and the challanges surrounding extremities and inflammation.

Introduction: After trauma, compartment syndrome of the extremities is a common, disabling, and-if managed suboptimally-lethal problem. Its treatment by surgical fasciotomy continues to be useful but controversial. The purpose of this survey is to measure survival and fasciotomy in a large trauma system to characterize trends and to determine if fasciotomy is associated with improved survival.Methods: We retrospectively surveyed data from a military trauma registry for U.S. casualties from 2001 to 2010. Casualties had extremity injury or extremity fasciotomy. We associated survival and fasciotomy.Results: Of 17,166 casualties in the total study, 19% (3,313) had fasciotomy and 2.8% (481) had compartment syndrome. Annual fasciotomy rates started at 0% (2001) and rose to 26% (2010). For all casualties, the survival rate initially was high (100%) but decreased steadily until its nadir (96.4%) in 2005. Thereafter, it increased to make a V-shaped trend with reversal occurring after fielding two interventions within the trauma system specifically for casualties at risk for fasciotomy-tourniquet use and a fasciotomy education program.Conclusions: Over a decade of war, the survival rate of extremity injured casualties was associated with two trauma system interventions-tourniquet usage and a fasciotomy education program. The current example of measuring implementation of initiatives may be useful as a model for future attempted improvements in health care. [ABSTRACT FROM AUTHOR]

Abstract: Background: Many pre-clinical and clinical researchers do not appreciate the recent decline in United States (US) population-level incidence of crack-cocaine smoking. At present, no more than about 200 young people start using crack-cocaine each day. Ten years ago, the corresponding estimated daily rate was 1000. This short communication looks into these trends, surrounding evidence on this important public health topic, and checks whether duration-reducing treatment interventions might be responsible, versus selected alternatives. Methods: Via analyses of standardized computer-assisted self-interview data from the US National Surveys on Drug Use and Health (NSDUH, 2002–2011; n >500,000), we evaluated change in incidence estimates, perceived difficulty to acquire crack, risk of using cocaine, treatment entries, and persistence once crack use has started. Results: We draw attention to a marked overall decline in year-specific incidence rates for crack-cocaine smoking from 2002 to 2011, especially 2007–2011. There is some variation in estimates of difficulty to acquire crack (p <0.001) and observed risk of using cocaine among ‘at risk’ susceptibles (p <0.001), but no appreciable shifts in duration of crack smoking among active users (p >0.05) or in proportion of crack users receiving treatment (p >0.05). Conclusions: Changing epidemiology of crack-cocaine smoking may rest largely on reductions in newly incident use with no major direct effects due to US cocaine treatment, incarceration, or interdiction. Concurrently, we see quite modest declines in survey-based estimates of cocaine-attributed perceived risk and cocaine availability. As such, we posit that no specific US agency should claim it is ‘riding to glory’ on the descending limb of this epidemic curve. [Copyright &y& Elsevier]

The article discusses a study on the antennae and maxillary palps of Rhagoletis suavis (Diptera: Tephritidae), a common pest of walnuts in eastern United States. It is mentioned that Rhagoletis fruit flies are important as major agricultural pests and as model organisms for the study of adaptation to new host plants and host race formation. A putative odorant receptor (OR), that is homologous to Drosophila melanogaster was found.

The article reports on a case study of a rehabilitation of a U.S. Army soldier with traumatic triple major limb amputations he acquired during combat operations in Iraq. Several amputations were performed to the soldier including left transdradial, right hip disarticulation, and left knee disarticulation. The author notes that the rehabilitation of a triple amputee is a challenge that will likely to become more common with the improved survivability of the modern battlefield.

The small crinoidal patch reef in the Bird Spring Formation near the mouth of Battleship Wash, Clark County, Nevada, has yielded the largest Early Permian crinoid fauna known in North America. Earlier studies of the fauna were based on 535 specimens. Additional collecting has yielded another 239 specimens. These new specimens provide new information about some of the earlier described species and include three new genera and seven new species, bringing the total recognized in the Battleship Wash fauna to 37 genera and 62 species. Representatives of the camerates, disparids, primitive cladids (cyathocrinitids and dendrocrinids), advanced cladids (formerly poteriocriniids), flexibles, and articulates are recognized in the Battleship Wash fauna. Of particular significance among these new specimens is the presence of an actinocrinid. A specimen formerly identified from the fauna is here recognized as an articulate. This is the first report of an actinocrinid and an articulate from the Permian of North America. Based on the abundance of large specimens of cladids with 10 or more arms, the Battleship Wash fauna is interpreted to have lived in a nearshore high energy shelf environment, which agrees with the paleogeographic position previously recognized for the Bird Spring Formation. New taxa introduced are: Poteriocrinites permicus n. sp., Bridgerocrinidae n. fam., Ekteinocrinus battleshipensis n. gen. and sp., Arroyocrius brachiatus n. sp., Plummericrinus jelli n .sp., Plummericrinus? bulbosus n. sp., Aesiocrinidae n. fam., Elassocrinus cyathus n. gen. and sp., Oklahomacrinus triangulus n. sp., and Pentaxocrinus quinarius n. gen. and comb. [ABSTRACT FROM AUTHOR]

Objective: To compare a small cellular clamshell phone with a traditional office phone in the development of discomfort and muscle fatigue over time during phone use.Background: Phone use involves low-level static exertions that may be influenced by phone design. Phone design and its interactions with anthropometry may change shoulder and hand postures assumed during use, which in turn may modify the length-strength relationship and moment arms of the muscles.Method: Ten adults participated in a study that simulated phone use using a small clamshell and a traditional office phone. Discomfort information and electromyographic (EMG) muscle activity were monitored on four upper extremity muscles. Discomfort and fatigue data (EMG median frequency shifts) were analyzed to assess differences between phones as well as differing effects attributable to anthropometry.Results: Median frequency shifts supported discomfort claims and indicated muscle fatigue in the deltoid and thenar muscles. Biomechanical measures demonstrated that participants with short limb lengths developed more severe signs of thenar fatigue. Participants with longer arms developed greater discomfort in the neck, shoulder, and back. The deltoid confirmed this occurrence, showing signs of muscle fatigue.Conclusion: Phone design and anthropometry influenced the development of discomfort and fatigue during phone use. Phone design dictated grip style, resulting in differing discomfort and fatigue levels. Anthropometry influenced the severity of the discomfort and fatigue present in the shoulder and hand.Application: Use of small clamshell phones may contribute to a lack of rest and recovery from typical workday exposures. It should be explored from an ergonomic perspective. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the effectiveness of laser-assisted angioplasty for patients with critical limb ischemia (CLI) who were poor candidates for surgical revascularization. Methods: A prospective registry at 14 sites in the US and Germany enrolled 145 patients with 155 critically ischemic limbs; the patients were poor candidates for bypass surgery owing to inadequate target vessel or saphenous vein, prohibitive cardiac disease, or significant comorbidities (ASA class 4). Additional comorbid risk factors included diabetes in 66%, hypertension in 83%, previous stroke in 21%, and myocardial infarction in 23%. Endovascular treatment included guidewire traversal and excimer laser angioplasty followed by balloon angioplasty with optional stenting. Results: Occlusions were present in 92% of limbs. A mean of 2.7 ± 1.4 lesions were treated per limb; the total median treatment length was 11 cm (mean 16.2, range 0.2-123). Stents were implanted in 45% of limbs. Procedural success, defined as <50% residual stenosis in all treated lesions, was seen in 86% of limbs. At 6-month follow up, limb salvage was achieved in 110 (92%) of 119 surviving patients or 118 (93%) 127 limbs. Conclusion: Excimer laser-assisted angioplasty for CLI offers high technical success and limb salvage rates in patients unfit for traditional surgical revascularization. [ABSTRACT FROM AUTHOR]

Presents clinical case reports on injuries in the upper extremities among athletes reported at the 2004 National Athletic Trainer's Association Annual Meeting & Clinical Symposia on June 19, 2004 in Baltimore, Maryland. "Radial Head Fracture and Displacement in a High School Football Player"; "Shoulder Pain and Crepitus Following Injury in a Collegiate Football Player"; "Elbow and Upper Arm Pain in a Collegiate Football Player."

Presents the text of oral presentations on ankle and balance in lower extremity among athletes at the 2004 National Athletic Trainer's Association Annual Meeting & Clinical Symposia on June 16, 2004 in Baltimore, Maryland. "Chronic Ankle Pain in a Collegiate Basketball Player"; "Risk Factors for Ankle Sprains in High School Athletes"; "Relationship Between Physical Activity and Balance in Physically Active and Sedentary Elders."

Examines alterations in lower extremity venous hemodynamics associated with normal pregnancy in women in California. Difference in venous filling index between left and right extremities; Evaluation of lower extremity venous physiology using air plethysmography; Relevance of residual volume fraction to venous dilation.

Medical devices are cleared for marketing approval through the Food and Drug Administration (FDA). Unique statutory requirements, such as the “least burdensome mandate,” have allowed the FDA to employ non-concurrent controls in its evaluation of prospective therapies. The use of Objective Performance Criteria and Goals (OPC and OPG) for the premarket evaluation of cardiovascular devices has become established as an alternative to randomized, controlled trials (RCTs). These single-armed comparisons may facilitate rapid entry of novel devices to the market. Unlike RCTs, they do not establish superiority or non-inferiority of the examined therapy, and study populations must be carefully inspected to ensure validity of comparisons to historical controls. [Copyright &y& Elsevier]

Background: Diabetes is associated with an increased risk for many birth defects and is likely to have an increasing impact on birth defect prevalence because of the rise in diabetes in the United States in recent decades. One of the first analyses in which specific birth defects were assessed for their relationship with both pregestational and gestational diabetes used data from the initial 6 years of the National Birth Defects Prevention Study. That analysis reported strong associations for pregestational diabetes with several birth defects, but few exposures among some of the less common birth defects led to unstable estimates with wide confidence intervals. Since that analysis, the study continued to collect data for another 8 years, including information on approximately 19,000 additional cases and 6900 additional controls.Objective: Our objective was to use data from the National Birth Defects Prevention Study, the largest population-based birth defects case-control study in the United States, to provide updated and more precise estimates of the association between diabetes and birth defects, including some defects not previously assessed.Study Design: We analyzed data on deliveries from October 1997 through December 2011. Mothers of case and control infants were interviewed about their health conditions and exposures during pregnancy, including diagnosis of pregestational (type 1 or type 2) diabetes before the index pregnancy or gestational diabetes during the index pregnancy. Using logistic regression, we separately assessed the association between pregestational and gestational diabetes with specific categories of structural birth defects for which there were at least 3 exposed case infants. For birth defect categories for which there were at least 5 exposed case infants, we calculated odds ratios adjusted for maternal body mass index, age, education, race/ethnicity, and study site; for defect categories with 3 or 4 exposed cases, we calculated crude odds ratios.Results: Pregestational diabetes was reported by 0.6% of mothers of control infants (71 of 11,447) and 2.5% of mothers of case infants (775 of 31,007). Gestational diabetes during the index pregnancy was reported by 4.7% of mothers of control infants (536 of 11,447) and 5.3% of mothers of case infants (1,653 of 31,007). Pregestational diabetes was associated with strong, statistically significant odds ratios (range, 2.5-80.2) for 46 of 50 birth defects considered. The largest odds ratio was observed for sacral agenesis (adjusted odds ratio, 80.2; 95% confidence interval, 46.1-139.3). A greater than 10-fold increased risk was also observed for holoprosencephaly (adjusted odds ratio, 13.1; 95% confidence interval, 7.0-24.5), longitudinal limb deficiency (adjusted odds ratio, 10.1; 95% confidence interval, 6.2-16.5), heterotaxy (adjusted odds ratio, 12.3; 95% confidence interval, 7.3-20.5), truncus arteriosus (adjusted odds ratio, 14.9; 95% confidence interval, 7.6-29.3), atrioventricular septal defect (adjusted odds ratio, 10.5; 95% confidence interval, 6.2-17.9), and single ventricle complex (adjusted odds ratio, 14.7; 95% confidence interval, 8.9-24.3). For gestational diabetes, statistically significant odds ratios were fewer (12 of 56) and of smaller magnitude (range, 1.3- 2.1; 0.5 for gastroschisis).Conclusion: Pregestational diabetes is associated with a markedly increased risk for many specific births defects. Because glycemic control before pregnancy is associated with a reduced risk for birth defects, ongoing quality care for persons with diabetes is an important opportunity for prevention. [ABSTRACT FROM AUTHOR]

Presents the text of oral presentations on hip function and lower extremity injuries of athletes at the 2004 National Athletic Trainer's Association Annual Meeting & Clinical Symposia on June 16, 2004 in Baltimore, Maryland. "Pelvis and Hip Neuromechanical Characteristics Predict Knee Biomechanics During a Stop-Jump Task"; "Gender Differences in Gluteus Medius Activity Exist in Soccer Players Performing a Forward Jump"; "The Relationship Between Core Strength and Pelvic Position of Female, Collegiate Volleyball and Soccer Athletes During Dynamic Activity."

The article informs that an unexpectedly high number of US soldiers injured in the Middle East and Afghanistan are testing positive for Acinetobacter baumannii, Army doctors reported. Between January 1, 2002 and August 31, 2004, a total of 102 cases of A. baumannii were diagnosed in soldiers at Walter Reed Army Medical Center in Washington, Landstuhl Regional Medical Center in Germany, and 3 other sites. A. baumannii, which is found in water and soil and is resistant to many types of antibiotics, surfaces occasionally in hospitals, often spread among patients in intensive care units. The infection was also seen in soldiers with traumatic injuries to their arms, legs, and extremities during the Vietnam War.

Presents the text of oral presentations on Hoffmann Reflex presented at the 2004 National Athletic Trainer's Association Annual Meeting & Clinical Symposia on June 18, 2004 in Baltimore, Maryland. "Intersession Reliability of a Protocol to Assess Reflex Activation History in the Vastus Medialis"; "Consistency of Hoffmann Reflex Measurement in Male Subjects Over a 28-Day Period"; "Lower Extremity Joint Kinematics Differ Between High School and College Female Athletes During Drop Landings."

The article focuses on the annual meeting of an editorial team held at Charlottesville in Virginia on October 21, 1995. Commissioning referees takes a tong time and waiting for their reports takes even longer. Merely raising their guilt by regular arm-twisting is both ineffective and unfair. And yet, in as much as this journal has established a high academic reputation, it has done so by the use of tight and wide-ranging refereeing procedures. This is a journal devoted to the community engaged in social studies of science and technology and advancing the discussions within that community is its primary goal.

The author thanks Palmer H. Futcher for his letter and the reprint of his valuable report on the article "A Peculiarity of Pigmentation of the Upper Arm of Negroes." The author was not aware of the article, as well as of Futcher's later article entitled "The Distribution of Pigmentation in the Arm and Thorax of Man," appearing in the Bulletin of the Johns Hopkins Hospital. While in his stay during 1916-17 at the Osborne Zoological Laboratory under direction of Professor R.G. Harrison, the author often visited the men's clinic of the county hospital, New Haven, Connecticut, in order to find such a pigmentation anomaly among patients, but in vain.

Presents statistical information on the prevalence of lower extremity disease among adults aged 40 years old with and without diabetes in the U.S. from 1999-2000.

The article reports on the results of a study on limb defects following exposure to chorionic villus sampling (CVS). The researchers also examined the data according to gestational age at which CVS was performed and found no correlation with the seventy of anomalies. Between May 1992 and May 1994, 63 European and U.S. centers participating in a World Health Organization registry reported 77 cases of limb defects following 138996 CVS procedures. The incidence of anomalies after CVS was 5-6 per 10,000 live births, lower than that in the general population. The research found no association between CVS and limb defects.