U.S. Blue Water Navy Veterans of the Vietnam War: Comparisons from the Vietnam Era Health Retrospective Observational Study (VE-HEROeS).

Background: US Vietnam War Blue Water Navy veterans (BWN) conducted military operations on Vietnam's offshore waters and likely experienced various war-related exposures. The overall health of the BWN has never been systematically studied. Purpose: Describe and compare BWN's health with other servicemembers and non-veterans of the Vietnam era. Materials and methods: Survey of 45 067 randomly selected US Vietnam War theatre and non-theatre veterans and 6885 non-veterans. Results: For 22 646 male respondents, self-reported health was contrasted by veteran status defined as BWN (n=985), theatre veterans (n=6717), non-theatre veterans (n=10 698) and non-veterans (n=4246). Exposure was service in the Vietnam War theatre. Collected were demographics, military service characteristics, lifestyle factors and health conditions. Adjusted odds ratios (aOR) were calculated using multivariable logistic regression. Controlling for cigarette smoking and other covariates, respiratory cancer risk was highest in BWN vs other veterans (theatre: aOR 1.65; 95% CI 1.09, 2.50; non-theatre: aOR 1.77; 1.13, 2.77) and to non-veterans (aOR 1.78; 1.15, 2.74). Other findings showed BWN's health risks between theatre and non-theatre veterans. Conclusion: There was a higher risk for respiratory cancers in BWN. Other risks were less than theatre veterans but greater than non-theatre or non-veterans, indicating a potential role of military exposures in BWN's health.

A new way to estimate neurologic disease prevalence in the United States: Illustrated with MS.

OBJECTIVE: Considerable gaps exist in knowledge regarding the prevalence of neurologic diseases, such as multiple sclerosis (MS), in the United States. Therefore, the MS Prevalence Working Group sought to review and evaluate alternative methods for obtaining a scientifically valid estimate of national MS prevalence in the current health care era. METHODS: We carried out a strengths, weaknesses, opportunities, and threats (SWOT) analysis for 3 approaches to estimate MS prevalence: population-based MS registries, national probability health surveys, and analysis of administrative health claims databases. We reviewed MS prevalence studies conducted in the United States and critically examined possible methods for estimating national MS prevalence. RESULTS: We developed a new 4-step approach for estimating MS prevalence in the United States. First, identify administrative health claim databases covering publicly and privately insured populations in the United States. Second, develop and validate a highly accurate MS case-finding algorithm that can be standardly applied in all databases. Third, apply a case definition algorithm to estimate MS prevalence in each population. Fourth, combine MS prevalence estimates into a single estimate of US prevalence, weighted according to the number of insured persons in each health insurance segment. CONCLUSIONS: By addressing methodologic challenges and proposing a new approach for measuring the prevalence of MS in the United States, we hope that our work will benefit scientists who study neurologic and other chronic conditions for which national prevalence estimates do not exist.

The Gulf War era multiple sclerosis cohort: 3. Early clinical features.

OBJECTIVES: To present clinical features at diagnosis for a large nationwide incident cohort of multiple sclerosis (MS) among those serving in the US military during the Gulf War era (GWE). MATERIALS & METHODS: Medical records and databases from the Department of Veterans Affairs (VA) for cases of MS with onset in or after 1990, active duty between 1990 and 2007 and service connection by the VA, were reviewed for diagnosis and demographic variables. Neurological involvement was summarized by the Kurtzke Disability Status Scale (DSS) and the Multiple Sclerosis Severity Score (MSSS). RESULTS: Among 1919 cases of clinically definite MS, 94% had a relapsing-remitting course and 6% were primary progressive at diagnosis. More males of all races and blacks of both sexes were progressive. At diagnosis, functional system involvement was pyramidal 69%, cerebellar 58%, sensory 55%, brainstem 45%, bowel/bladder 23%, cerebral 23%, visual 18%, and other 5%. Mean DSS scores were: white males, females 2.9, 2.7; black males, females 3.3, 2.8; and other-race males, females 3.2, 2.6. Mean and median MSSS were marginally greater in black males and other males compared to the other sex-race groups. CONCLUSIONS: In this incident cohort, males and blacks had significantly higher proportions of primary progressive MS. DSS at diagnosis was significantly more severe in blacks and significantly less so in whites and in women vs men, but MSSS was only marginally greater in black males and other-race males. This morbidity assessment early in the course of MS provides population-based data for diagnosis, management, and prognosis.

Multistate Outbreak of Human Salmonella Typhimurium Infections Linked to Pet Hedgehogs - United States, 2011-2013.

Zoonotic Salmonella infections cause approximately 130 000 illnesses annually in the United States. Of 72.9 million US households owning at least one pet, five million own small mammals; 3000 hedgehogs were documented by USDA in USDA-licensed breeding facilities and pet stores in 2012. State health department collaborators and PulseNet, the national bacterial subtyping network, identified human infections of a Salmonella Typhimurium outbreak strain, which were investigated by CDC, USDA-APHIS and state public and animal health officials. A case was defined as an illness in a person infected with the outbreak strain identified between 1 December 2011 and 3 June 2013. Investigators collected information on patient exposures, cultured animal and environmental specimens for Salmonella, and conducted traceback investigations of USDA-licensed hedgehog facilities. There were 26 cases in 12 states. Illness onset dates ranged from 26 December 2011 to 8 April 2013. The median patient age was 15 years (range = <1-91 years); 58% were female. Among 23 persons with available information, 8 (35%) were hospitalized and one outbreak strain-associated death was reported. Of 25 patients with available information, 20 (80%) reported pet hedgehog contact in the week before illness onset. The outbreak strain was isolated from animal and environmental samples collected from three ill persons' homes in three states. Hedgehogs were purchased in geographically distant states from USDA-licensed breeders (10/17, 59%); a USDA-licensed pet store (1/17, 6%); unlicensed or unknown status breeders (3/17, 18%); and private individuals (3/17, 18%). Traceback investigations of USDA-licensed facilities did not reveal a single source of infection. Public and animal health collaboration linked pet hedgehog contact to human infections of Salmonella Typhimurium, highlighting the importance of a One Health investigative approach to zoonotic salmonellosis outbreaks. More efforts are needed to increase awareness among multiple stakeholders on the risk of illness associated with pet hedgehogs.

Sequential administration of GM-CSF (Sargramostim) and IL-2 +/- autologous vaccine as adjuvant therapy in cutaneous melanoma: an interim report of a phase II clinical trial.

Granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin-2 (IL-2) are 2 cytokines with distinct mechanisms of action that complement one another in the adjuvant management of melanoma. Forty-five patients with high-risk melanoma were enrolled in an open-label, single-arm, phase II clinical trial to examine the safety, tolerability, and effectiveness of this combination. After potentially curative surgery, each patient received 12 months of GM-CSF 125 microg/m2/d subcutaneously (SC) for 14 days followed by IL-2, 9 million IU/m2/d SC for 4 days (given every other cycle from months 7-12), followed by 10 days of no treatment. In addition, patients who had tumors yielding an adequate number of live cells received autologous melanoma vaccines. For months 13-24, patients received only GM-CSF 250 microg/m2 twice weekly. This is an interim analysis based on the 45 enrolled patients with a median of 15.9 months follow-up (range, 1-50 months). Thirty-two patients are alive: 9 of 13 with stage IV resected melanoma, 16 of 25 with stage III disease, and 7 of 7 with stage II disease. Twelve died of the disease, and one due to stroke. Adjuvant use of sequential GM-CSF and IL-2 +/- autologous vaccine was well tolerated with good patient compliance and seemed to benefit high-risk patients with surgically resected melanoma.

Patient self-testing of prothrombin time after hip arthroplasty.

We determined whether total hip arthroplasty (THA) patients could test their own prothrombin time reliably over 6 weeks of anticoagulation prophylaxis with a portable device that measures prothrombin time and whether self-testing would improve or maintain the quality of care at a lower cost than our standard procedure. Forty-six THA patients participated in the study and were compared with a matched group managed with our standard protocol using a home health-care nurse. Seven patients (15%) could not be trained to obtain the blood sample, and others required multiple finger sticks to obtain valid results. However, the results from the 29 patients completing the study showed high reliability when compared with results obtained through standard protocol. Self-testing saved about $260 per patient over the cost of venipuncture. Patient self-testing of prothrombin time using the device in this study is reliable and cost-effective for monitoring the anticoagulation status after THA in a select group of elderly patients.

Osteonecrosis of the femoral head treated with cementless total hip arthroplasty.

BACKGROUND: The treatment of young patients who have osteonecrosis of the femoral head associated with collapse or substantial secondary degeneration remains a therapeutic challenge, with total hip arthroplasty being a treatment of choice. However, concerns about the durability of the results of hip arthroplasty in this population necessitate long-term evaluation of this treatment option. To determine its advantages and limitations, we evaluated the results of cementless total hip arthroplasty in a consecutive series of young patients with advanced osteonecrosis. METHODS: We reviewed the results of fifty-five consecutive primary total hip arthroplasties, after an average of 117 months of follow-up, in forty-five patients with a preoperative diagnosis of advanced osteonecrosis of the femoral head (Ficat and Arlet stage III or IV). The average age was thirty-one years (range, twenty-one to forty years) at the time of the operation. We collected data prospectively with the use of patient questionnaires and radiographs. RESULTS: Five patients died and one patient was lost to follow-up before the time of the minimum five-year follow-up; this left forty-eight hips in thirty-nine patients for inclusion in the study. Ten (21 percent) of the forty-eight hips required revision. No revisions were due to aseptic failure of the femoral component. Of the remaining twenty-nine patients (thirty-eight hips), twenty-seven (93 percent) reported few or no functional limitations and twenty-three (79 percent) could walk an unlimited distance at the time of the latest follow-up. Pain was absent or mild in twenty-five patients (86 percent). Twenty-three patients (79 percent) were employed full-time. Radiographically, thirty-seven femoral components (97 percent) were bone-ingrown and the remaining component was judged to be fibrous stable. All thirty-eight acetabular components were bone-ingrown. CONCLUSIONS: Cementless total hip arthroplasty remains a reasonable treatment option for advanced osteonecrosis of the femoral head. Wear of the bearing surface continues to limit the long-term success rate, but we are encouraged by the predictable long-term stability of the bone-implant interface achieved with cementless fixation. These results compare favorably with those of published reports of total hip arthroplasty with cement in younger patients with osteonecrosis.

Live transmission of neonatal echocardiograms from underserved areas: accuracy, patient care, and cost.

OBJECTIVE: Echocardiography is an important tool in the diagnosis and management of critically ill neonates. The authors hypothesized that live telemedicine guidance and interpretation of neonatal echocardiograms from underserved areas would improve management, prevent unnecessary transports, enhance sonographer proficiency, and result in monetary savings. MATERIALS AND METHODS: Using personal computers capable of real-time transmission of echocardiograms over three integrated services digital network (ISDN) telephone lines, pediatric cardiologists interpreted echocardiograms, suggested views to sonographers, and made recommendations to neonatologists 200 miles away. Analyses of accuracy, management, echocardiogram quality, time, and costs were carried out prospectively. RESULTS: Sixty studies were transmitted over 7 months. Indications for echocardiography were suspected congenital heart disease (n = 29), suspected patent ductus arteriosus (PDA) (n = 27), and hemodynamic instability (n = 4). Diagnoses were critical congenital heart disease (n = 4), noncritical heart disease (n = 8), PDA (n = 21), ventricular dysfunction (n = 5), persistent pulmonary hypertension (n = 3), and normal (n = 19). Videotape review confirmed all telemedicine interpretations. The echocardiogram led to immediate change in management in 25 cases (42%), and echocardiogram quality was improved in 53 studies (88%). Time from request to completion of echocardiography was 43+/-30 min. Monetary savings from five avoided transports exceeded all expenses. CONCLUSION: Live transmission of neonatal echocardiograms over three ISDN lines is diagnostic, improves patient care and echocardiography quality, and is cost effective.

Total hip arthroplasty with porous-coated prostheses fixed without cement in patients who are sixty-five years of age or older.

We reviewed the results of 212 total hip arthroplasties performed without cement in 203 unselected, consecutive patients who were sixty-five years of age or older. The outcome was known for 196 hips, thirty-seven of which had been followed until the death of the patient and 159 of which had been followed for a minimum of five years. A reoperation was done in 4 percent (seven) of the 196 hips. These reoperations included one revision because of loosening of the stem and five revisions of the cup. Three of the acetabular revisions were done because of fracture due to polyethylene wear; one, because of recurrent dislocation; and one, because of polyethylene wear and a fracture due to lysis. In the seventh reoperation, a cup and stem were exchanged because of infection. The probability that a hip prosthesis would survive twelve years without a reoperation was 0.92 (95 percent confidence interval, 0.85 to 0.99). We evaluated the clinical results for 152 patients who had not had a reoperation and had been followed for at least five years (mean, 8.5 years; range, five to fourteen years). Of these patients, thirteen (9 percent) had pain that limited activity: five (3 percent) had pain in the thigh (four patients) or groin (one patient), and eight (5 percent) had trochanteric pain and tenderness. One hundred and forty-four (95 percent) of the patients noted an improvement in overall function, and 149 (98 percent) reported satisfaction with the outcome. One hundred and thirty-five hips that were not revised were followed radiographically for at least five years (mean, 8.2 years; range, five to fourteen years). In this group, osteolysis was observed in three hips (2 percent); loosening of the cup, in three (2 percent); and loosening of the stem, in one (1 percent). Stress-shielding was seen on the two-year postoperative radiographs of forty-five (26 percent) of the 174 hips that were followed for at least that duration. The prevalence of osteolysis, loosening of a component, and reoperations was no greater in this subgroup than in the overall group. These results indicate that total hip arthroplasty without cement can be successful in older patients. This study also provides a reference for comparison with the results of total hip arthroplasty performed with cement and those of so-called hybrid total hip arthroplasty (an acetabular component fixed without cement and a femoral component fixed with cement) in patients who are sixty-five years of age or older.

Revision of loose cementless femoral prostheses to larger porous coated components.

The results of 21 revision hip arthroplasties were reviewed. The indication for each revision was a symptomatically loose porous coated femoral component. The loose stems were all replaced with Anatomic Medullary Locking stems. In 16 of the 21 procedures, the acetabular component also was revised. Complications included two intraoperative femoral fractures, one sciatic nerve palsy, and one case of multiple hip dislocations. The mean Harris Hip Score was significantly improved from a mean of 42 points (range, 23-90 points) preoperatively to a mean of 84 points (range, 59-100 points) 6.3 years after the revision. Ninety-five percent of the patients reported less severe hip pain. Ninety percent had improved walking ability. Eighty-five percent stated that they were satisfied with the results of the revision procedure. No femoral component has shown radiographic or clinical signs of repeat loosening, and none have been rerevised. It was concluded that when a cementless femoral component becomes symptomatically loose, replacing the loose stem with a larger and more extensively porous coated component is a successful method for achieving better implant fixation.

Internuclear cascade-evaporation model for LET spectra of 200 MeV protons used for parts testing.

The Linear Energy Transfer (LET) spectrum produced in microelectronic components during testing with 200 MeV protons is calculated with an intemuclear cascade-evaporation code. This spectrum is compared to the natural space heavy ion environment for various earth orbits. This comparison is used to evaluate the results of proton testing in terms of determining a firm upper bound to the on-orbit heavy ion upset rate and the risk of on-orbit heavy ion failures that would not be detected with protons.

Total hip arthroplasty. Concerns with extensively porous coated femoral components.

A series of 507 consecutive, unselected cementless hip arthroplasties performed by one surgeon was reviewed to address specifically potential concerns with the use of extensively coated femoral components, including the frequency and nature of reoperation, thigh pain, component stability, osteolysis, and stress shielding. Excluding hips in patients who had died or were lost to followup, there were 426 hips with minimum 5-year followup. The overall femoral reoperation rate of 2.6% (13 cases) included seven for failure of fixation and six for osteolysis. Of the unrevised cases, 96% of the femoral components showed radiographic bone ingrowth, and 3.7% showed a stable fibrous pattern. Fixation did not deteriorate with time. A 2.9% incidence of activity limiting thigh pain did affect clinical outcome (limp, ambulation tolerance, support), but there were no clinical or radiographic predisposing variables. There was no detectable femoral osteolysis in 88.3% of cases. The remainder had lesions confined to Gruen Zones 1 and 7, suggesting that circumferential extensive coating was protective against distal osteolysis. Although osteolysis did not affect component stability, in six cases it did result in pathologic trochanteric fracture, contributing to the frequency of reoperation. Stress shielding was common (25%) and was related to older patients and the use of larger diameter stems (> 15 mm), but did not predispose to thigh pain, loosening, osteolysis, or an inferior clinical result. These results documented the clinical and radiographic success in the use of extensively coated cementless femoral components. Debris generation from wear and resulting osteolysis remain significant concerns in a hip arthroplasty with this design as with many others. However, concerns about the high incidence of reoperation, thigh pain, component instability, or stress shielding are not supported by this study.

Evaluation of an inservice training program on dementia and wandering.

This study assessed the impact of an inservice training program in four nursing homes on nursing staff's knowledge of dementia, pacing/wandering behavior and management strategies, staff satisfaction, and their perceptions of work difficulty and quality of care. Additionally, unit-level behavioral observations of agitated behavior and the nature of resident interactions with staff members and other residents were also performed to assess whether changes in nursing staff's knowledge impacted the residents or interactions with the residents. Analyses revealed that quiz scores were significantly improved immediately following the inservice program as compared to pretest but returned to near pretest levels at the 1-month follow-up. Additionally, nursing staff reported that residents were allowed to pace/wander to a greater extent at follow-up compared to pretest. Methods for improving the effectiveness of inservice training are discussed.

Treatment of complications in primary cementless total hip arthroplasty.

Five hundred eight consecutive cases (481 patients) treated with the extensively porous coated Anatomic Medullary Locking prosthesis were followed for an average of 9 years (range, 5-14 years). Thirty-one (6%) hips were lost to followup and 33 (7%) hips had complications that required revision surgery. The indications for revision were symptomatic stem loosening (six cases), symptomatic cup loosening (five cases), asymptomatic periarticular osteolysis (seven cases); trochanteric fracture through an osteolytic cyst (four cases), polyethylene fracture (five cases), sepsis (one case), and heterotopic ossification (one case). The surgical treatment of these complications is described. After these revisions, 11 (33%) cases had additional complications, most commonly a dislocation. Four required a second revision. Questionnaires and physical examinations were used to compare the outcome of the cases requiring revision with the outcome of those that did not. There were no differences in patient satisfaction between cases requiring revision surgery and those that did not (97% and 95% patient satisfaction, respectively). Function was also similar between the two groups, with 93% reporting increased function in each group.

Assessment of ambulatory behavior in nursing home residents who pace or wander: a comparison of four commercially available devices.

This study evaluated four devices--a Pedometer, Step Sensor, Actigraph, and Personal Activity Meter (PAM)--as measures of pacing behavior. Ten nursing home residents who frequently paced in a long-term care facility underwent 1 day of data collection with each of the devices. Data derived from devices were compared to behavioral observations regarding the number of steps taken. Additionally, devices were evaluated via ratings concerning ease of use, and how well residents tolerated them. All devices yielded high correlations with the observed number of steps, with highest correlations for the PAM and Actigraph. All devices were tolerated well. The Pedometer and Step Sensor were the easiest to use. This study demonstrated that these devices offer an objective means to measure pacing/wandering behavior.

Femoral fixation in primary total hip arthroplasty.

We have presented the major advantages of using femoral components that have porous coating over the entire stemmed portion and have a cylindrical distal shape. The advantages of a stem with these design features also are reflected in the changing pattern of hip implant usage. A decade ago, the most frequently used porous-coated implants were those designed predominantly for metaphyseal fixation. At that time, the only commercially available, extensively porous-coated stem with a cylindrical distal stem shape was the anatomic medullary locking (AML) prosthesis. Currently, the most commonly used porous-coated prosthesis is the extensively porous-coated AML. Virtually all implant manufacturers now make a stem with design features similar to the AML. While concerns about stress shielding and prosthesis removal remain, they have not proven to be a clinical problem in our experience. We have used these stems in all of our primary total hip arthroplasties for 20 years and continue to do so.

Long-term clinical consequences of stress-shielding after total hip arthroplasty without cement.

Remodeling of the femur, or so-called stress-shielding, was observed on the two-year postoperative radiographs of forty-eight (23 per cent) of 207 hips that were part of a consecutive, non-selected series of 223 hips that had had a primary arthroplasty with use of the anatomic medullary locking hip system. Three patients (three hips) died within ten years after the arthroplasty, leaving forty-four patients (forty-five hips) who had a minimum of ten years of clinical follow-up. At the time of the latest follow-up, thirty-eight patients (86 per cent) reported that they had either no or mild pain related to the hip, forty-two (95 per cent) had less pain than they had had preoperatively, and forty-one (93 per cent) were satisfied with the results of the arthroplasty. Two patients had a reoperation, but neither procedure involved the femoral component; specifically, one patient had a revision of a loose acetabular component and one had an exchange of a polyethylene liner. No femoral component was associated with clinical or radiographic evidence of loosening. Femoral osteolysis, confined to zones 1 and 7 of Gruen et al., was observed on the ten-year radiographs of four of the thirty-three hips for which such radiographs were available. Stress-shielding (defined as evidence of pronounced femoral bone-remodeling on the two-year radiographs) had not adversely affected the outcome for these four hips by the time of the latest follow-up. The findings regarding postoperative pain, function, and over-all satisfaction for the forty-four patients (forty-five hips) who were included in the present study were similar to those reported for our larger (parent) series of patients who had been managed with the anatomic medullary locking hip system and to those reported for a similar series of patients who were followed for 9.5 years after the insertion of a porous-coated anatomic prosthesis. In addition, the prevalence of acetabular and femoral osteolysis (four [12 per cent] of thirty-three hips) and that of revision of the femoral component (zero [0 per cent] of forty-five hips) were lower than those for our larger (parent) series (fifty-four [39 per cent] of 137 hips and three [1 per cent] of 201 hips, respectively) as well as those for the series of patients who had been managed with the porous-coated anatomic prosthesis (thirty-five [45 per cent] and four [5 per cent] of seventy-eight hips, respectively).

Long-term results of use of the anatomic medullary locking prosthesis in total hip arthroplasty.

A total hip arthroplasty was performed, with use of the anatomic medullary locking hip system, in 223 consecutive, non-selected hips in 215 patients. The mean age of the patients at the time of the operation was fifty-five years (range, sixteen to eighty-seven years). Twenty-one patients (twenty-two hips) were lost to follow-up and twenty-seven patients (twenty-seven hips) died less than ten years postoperatively. The remaining 167 patients (174 hips) were followed for a minimum of ten years (mean, eleven years; maximum, thirteen years). There were twenty reoperations involving a component. The rate of survival at twelve years was 0.97 +/- 0.02 (mean and standard error) for the stem and 0.92 +/- 0.03 for the cup. Patients who had osteolysis were younger than those who did not have osteolysis (mean age, forty-seven compared with fifty-six years; p < 0.01). Similarly, patients who had a reoperation were younger than those who did not have a reoperation (mean age, forty-six compared with fifty-four years; p < 0.01). The radiographic appearance of progressive wear that, in our opinion, was severe enough to cause the femoral head to completely penetrate the polyethylene liner was the most frequent reason for reoperation.

Risk assessment for heavy ions of parts tested with protons.

An internuclear cascade-evaporation code is used to model energy deposition in thin slabs of silicon. This model shows that protons produce a significant number of events with effective Linear Energy Transfer (LET) greater than 8 MeV cm2/mg and demonstrates that proton testing of microelectronic components can be an effective way to screen devices for low earth orbit susceptibility to heavy ions.

Longitudinal changes in cognitive functioning in adult day care participants.

This study examines longitudinal changes in cognitive functioning over the course of 2 years in participants of adult day cae programs. Cognitive measures included the Brief Cognitive Rating Scale (BCRS) and the Mini-Mental State Examination (MMSE). Longitudinal data were available for five measurement points over 2 years for 82 participants (22 males and 60 females). Overall, results from this study suggest that there were significant cognitive declines on BCRS and MMSE, even after only 1 or 2 years in the study. The rates of impairment over the 2 years for BCRS and MMSE were highly correlated. Within each measure, the individual rates of decline were very heterogenous and were influenced by the presence, type, and prognosis of dementia. Participants with multi-infarct dementia had greater cognitive decline than did those with other types of dementias. Initial cognitive functioning and physician's prognosis of dementia trajectory were also significant predictors of change over time. Results suggest a floor effect in the BCRS.