The developing juvenile talus: Radiographic identification of distinct ontogenetic phases and structural trajectories.

Trabecular bone architecture in the developing skeleton is a widely researched area of bone biomechanics; however, despite its significance in weight-bearing locomotion, the developing talus has received limited examination. This study investigates the talus with the purpose of identifying ontogenetic phases and developmental patterns that contribute to the growing understanding of the developing juvenile skeleton. Colour gradient mapping and radiographic absorptiometry were utilised to investigate 62 human tali from 38 individuals, ranging in age-at-death from 28 weeks intrauterine to 20 years of age. The perinatal talus exhibited a rudimentary pattern comparable to the structural organisation observed within the late adolescent talus. This early internal organisation is hypothesised to be related to the vascular pattern of the talus. After 2 years of age, the talus demonstrated refinement, where radiographic trajectories progressively developed into patterns consistent with adult trabecular organisation, which are linked to the forces associated with the bipedal gait, suggesting a strong influence of biomechanical forces on the development of the talus.

External Validation and Updating of a Statistical Civilian-Based Suicide Risk Model in US Naval Primary Care.

Importance: Suicide remains an ongoing concern in the US military. Statistical models have not been broadly disseminated for US Navy service members. Objective: To externally validate and update a statistical suicide risk model initially developed in a civilian setting with an emphasis on primary care. Design, Setting, and Participants: This retrospective cohort study used data collected from 2007 through 2017 among active-duty US Navy service members. The external civilian model was applied to every visit at Naval Medical Center Portsmouth (NMCP), its NMCP Naval Branch Health Clinics (NBHCs), and TRICARE Prime Clinics (TPCs) that fall within the NMCP area. The model was retrained and recalibrated using visits to NBHCs and TPCs and updated using Department of Defense (DoD)-specific billing codes and demographic characteristics, including expanded race and ethnicity categories. Domain and temporal analyses were performed with bootstrap validation. Data analysis was performed from September 2020 to December 2022. Exposure: Visit to US NMCP. Main Outcomes and Measures: Recorded suicidal behavior on the day of or within 30 days of a visit. Performance was assessed using area under the receiver operating curve (AUROC), area under the precision recall curve (AUPRC), Brier score, and Spiegelhalter z-test statistic. Results: Of the 260 583 service members, 6529 (2.5%) had a recorded suicidal behavior, 206 412 (79.2%) were male; 104 835 (40.2%) were aged 20 to 24 years; and 9458 (3.6%) were Asian, 56 715 (21.8%) were Black or African American, and 158 277 (60.7%) were White. Applying the civilian-trained model resulted in an AUROC of 0.77 (95% CI, 0.74-0.79) and an AUPRC of 0.004 (95% CI, 0.003-0.005) at NBHCs with poor calibration (Spiegelhalter P < .001). Retraining the algorithm improved AUROC to 0.92 (95% CI, 0.91-0.93) and AUPRC to 0.66 (95% CI, 0.63-0.68). Number needed to screen in the top risk tiers was 366 for the external model and 200 for the retrained model; the lower number indicates better performance. Domain validation showed AUROC of 0.90 (95% CI, 0.90-0.91) and AUPRC of 0.01 (95% CI, 0.01-0.01), and temporal validation showed AUROC of 0.75 (95% CI, 0.72-0.78) and AUPRC of 0.003 (95% CI, 0.003-0.005). Conclusions and Relevance: In this cohort study of active-duty Navy service members, a civilian suicide attempt risk model was externally validated. Retraining and updating with DoD-specific variables improved performance. Domain and temporal validation results were similar to external validation, suggesting that implementing an external model in US Navy primary care clinics may bypass the need for costly internal development and expedite the automation of suicide prevention in these clinics.

The developing juvenile distal tibia: Radiographic identification of distinct ontogenetic phases and structural trajectories.

A novel combination of radiographic colour gradient mapping and radiographic absorptiometry was utilised to examine 96 human distal tibiae from 54 individuals ranging in age-at-death from the foetal to 23 years. The purpose of this was to identify previously undocumented changes in the internal organisation during the development of the distal tibia and determine whether these changes could be described as distinct phases. Previous studies have demonstrated a rudimentary structural organisation in other skeletal elements that mirror more mature patterns of bone organisation. Results showed that the perinatal tibia did not exhibit a rudimentary structural pattern similar to the architecture observed within the late adolescent tibia. This lack of early internal organisation is hypothesised to be related to the rudimentary ossification process that is being laid down around a pre-existing vascular template which will be subsequently modified by locomotive forces. Between birth and 2 years of age, the tibia exhibited a period of regression where radiodensity decreased in comparison to the perinatal tibia. This period of regression was postulated to be due to a combination of factors including changing locomotive forces, weaning and growth resulting in a stage of development which is extremely demanding on calcium liberation from the skeleton. After 2 years of age, the distal tibia demonstrated refinement where radiographic trajectories progressively developed into patterns consistent with adult trabecular organisation. These trajectories are linked to the forces associated with the bipedal gait, suggesting a strong influence of biomechanical forces on the development of the distal tibia.

The Association of Skin Cancer Prevention Knowledge, Sun-Protective Attitudes, and Sun-Protective Behaviors in a Navy Population.

INTRODUCTION: U.S. Navy service members are primarily between the ages of 18 and 30 years and often required to be outside for extended periods of time in geographical locations with increased and often unfamiliar ultraviolet indexes that collectively increase their risk for skin cancer. Skin cancer is the country's most common form of cancer, yet there is a paucity of skin cancer prevention literature, especially within the U.S. Navy. The purpose of this study was to describe skin cancer risk and skin cancer prevention "cues-to-action" and to determine if skin cancer prevention knowledge was associated with sun-protective attitudes (e.g., prevention perceptions, benefits, threats, barriers, and sun-protective behavior self-efficacy) and sun-protective behaviors (e.g., wearing long sleeve shirts and using sunscreen and not deliberately exposing skin for a tan) in a Navy population. MATERIALS AND METHODS: A cross-sectional, descriptive, correlational design was utilized, and the study approval was obtained by the Naval Medical Center Portsmouth Institutional Review Board. Two-hundred twenty-nine active duty Navy service members aged 18-30 years who presented to primary care for their periodic health assessment completed the Brief Skin Cancer Risk Assessment and the Skin Cancer Survey. Descriptive statistics were utilized to assess service members' perceptions and knowledge regarding skin cancer prevention along with sociodemographic characteristics. The Spearman rank-order correlation and the Mann-Whitney U test were used to assess associations. P-values <.05 were used to determine statistical significance. RESULTS: Skin cancer prevention knowledge was significantly related to sun-protective behavior self-efficacy (r = 0.218, P = .001), benefits (r = 0.271, P ≤ .001), sun protection behaviors (r = 0.152, P = .024), skin cancer risk (r = 0.256, P = .001), current frequency of high-risk sun behavior (r = 0.183, P = .006), past frequency of high-risk sun behavior (r = 0.219, P = .001), sun exposure (U = 4,813.50, P = .005), tanning bed use (U = 3,154.50, P = .031), and training (U = 4,099.50, P = .005). CONCLUSIONS: Integrating skin cancer education into primary care visits (i.e., periodic health assessments) may improve Navy service members' modifiable sun-protective attitudes and behaviors and may contribute to lowering future skin cancer rates.

A psychometric assessment of the Military Suicide Attitudes Questionnaire (MSAQ).

Suicide rates remain high among military populations. Stigmatizing beliefs about suicide contribute to the problem of heightened suicide risk as a deterrent for help-seeking. Measurement of military suicide stigma is therefore an important gap in the literature as a necessity toward the development of military suicide prevention programming. This paper assessed the factor structure, reliability, and validity of the Military Suicide Attitudes Questionnaire (MSAQ). Study 1 featured secondary analysis of a suicide risk dataset from active duty treatment-seeking military personnel (N = 200). Study 2 was a secondary analysis of a statewide assessment of Army National Guard service members' beliefs about mental health and suicide (N =1116). Factor analyses results collectively supported a four-factor Military Suicide Attitudes Questionnaire (MSAQ) structure: discomfort, unacceptability, support, and empathic views. Subscale reliabilities ranged from 0.77 to 0.83 across samples. Unacceptability and support displayed significant negative correlations with psychological distress. Men displayed more negative suicide-related beliefs compared to women counterparts. Discomfort and unacceptability beliefs displayed significant positive associations with perceived barriers to care. The final short version of the MSAQ is an efficient, multi-dimensional measure of military suicide-related beliefs. The instrument can be used for public health assessment and program evaluation in military settings.

Preferences in Information Processing: Understanding Suicidal Thoughts and Behaviors among Active Duty Military Service Members.

The present study examined Preferences in Information Processing (PIP), an emerging model of understanding suicidal thoughts and behaviors (STBs), in a clinical military sample for the first time. Constructs of need for affect (NFA; i.e., extent to which one engages or avoids emotional content) and need for cognition (NFC; i.e., extent of preference for and enjoyment of cognitive effort) are central individual differences of the PIP model hypothesized to be associated with STBs. Data (n = 200 active duty personnel) were drawn from medical records and self-report questionnaires from two outpatient treatment settings in a military hospital. Primary findings include: (1) moderate positive bivariate associations of NFA avoidance with mental health symptoms and lifetime STBs; (2) consistent patterns in which NFA approach buffers the negative associations of depression with life STBs, clinical suicide risk, perceived burdensomeness and thwarted belonging. Recommendations are offered for military suicide prevention, and future suicide theory testing.

Psychometric evaluation of the Suicide Cognitions Scale-Revised (SCS-R).

The measurement of self-reported suicide risk can be complicated in medical settings due to patient apprehension about the potential consequences of self-disclosure. The Suicide Cognitions Scale (SCS) was designed to assess suicide risk by measuring a range of suicidogenic cognitions (e.g., hopelessness, perceived burdensomeness) collectively referred to as the suicidal belief system. The SCS's concurrent, known groups, and prospective validity for suicidal thoughts and behaviors have previously been supported. The present study examined the factor structure, known-groups, and concurrent validity of a revised, 16-item version of the SCS (SCS-R), which removed two items that explicitly used the word "suicide" and changed item scoring from a 1-5 to 0-4 scale, thereby improving the interpretation of scores. In a sample of 2,690 primary care patients presenting for routine medical care at one of six US military clinics, results of bifactor analysis supported the scale's unidimensionality. The SCS-R significantly differentiated participants with a history of suicide attempts and was significantly correlated with frequency of thoughts about death and self-harm during the previous 2 weeks. Results align with earlier research and provide psychometric support for the SCS-R.

Improving Suicide Risk Screening to Identify the Highest Risk Patients: Results From the PRImary Care Screening Methods (PRISM) Study.

PURPOSE: Over 95% of patients who screen positive on the Patient Health Questionnaire-9 (PHQ-9) suicide risk item do not attempt or die by suicide, which could lead to unnecessary treatment and/or misallocation of limited resources. The present study seeks to determine if suicide risk screening can be meaningfully improved to identify the highest-risk patients. METHODS: Patients eligible to receive medical treatment from the US Department of Defense medical system were recruited from 6 military primary care clinics located at 5 military installations around the United States. Patients completed self-report measures including the PHQ-9 and 16 items from the Suicide Cognitions Scale (SCS) during routine primary care clinic visits. Postbaseline suicidal behaviors (suicide attempts, interrupted attempts, and aborted attempts) were assessed by evaluators who were blind to screening results using the Self-Injurious Thoughts and Behaviors Interview. RESULTS: Among 2,744 patients, 13 (0.5%) engaged in suicidal behavior in the 30 days after screening and 28 (1.0%) displayed suicidal behavior in the 90 days after screening. Multiple SCS items differentiated patients with suicidal behavior less than 30 days after screening positive for suicide risk. Augmenting the PHQ-9 suicide risk item with SCS items improved the identification of patients who were most likely to have suicidal behavior within a month of screening positive without sacrificing sensitivity. CONCLUSION: Among primary care patients who screen positive for suicide risk on the PHQ-9, SCS items improved screening efficiency by identifying those patients who are most likely to engage in suicidal behavior within the next 30 days.

Psychometric assessment of two suicide screeners when used under routine conditions in military outpatient treatment programs.

Suicide remains a pressing problem among active-duty military personnel. Recent Department of Veterans Affairs and Department of Defense suicide prevention practice guidelines highlight the need for further screening research. The present study assessed the psychometric properties of 2 common self-report suicide screening tools: the Suicidal Behaviors Questionnaire-Revised (SBQ-R) and the Columbia Suicide Severity Rating Scale (C-SSRS) ideation subscale. Data (n = 200 active-duty personnel) were drawn from medical records and self-report questionnaires from 2 outpatient treatment settings in a military hospital. Primary findings include: (a) confirmatory factor analytic support for the SBQ-R but not the self-report version of the C-SSRS ideation severity subscale; and (b) acceptable reliability for both the SBQ-R and C-SSRS ideation severity subscale. Recommendations are offered for military suicide screening practice and research. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

NICU Fathers: Improving the Quality of Paternal Support in the NICU.

BACKGROUND: Parental support in the neonatal intensive care unit (NICU) is critical; yet, the nursing staff may struggle to provide optimal support to NICU fathers. Generally, fathers are not viewed as equally competent caregivers when compared with mothers, and fathers often impart these beliefs on themselves. Increasing the nursing staff's knowledge and understanding of paternal support can change attitudes and foster positive behavior changes, enhancing the perception of support received by NICU fathers. PURPOSE: To implement a needs assessment and educational intervention for the nursing staff designed to increase the perception of nursing support received by NICU fathers. METHODS: The Nurse Parents Support Tool (NPST) was administered to the clinical nursing staff and fathers in a pre/posttest design comparing support given by nurses with the fathers' perception of received support. Data from the preintervention assessment was used to design an educational intervention on improving fathers' support. Following the intervention, a postintervention NPST was administered to fathers to determine whether there was an improvement in support perception. FINDINGS/RESULTS: Improvement in the NICU fathers' perception of nursing staff support was noted between father groups. In addition, the NPST can be used to assess paternal support needs and develop staff education. IMPLICATIONS FOR PRACTICE: Support provided to NICU fathers can enhance the father's perception of himself as an equal and competent caregiver, leading to improved father-infant bonding as the child ages. Educational interventions targeting father support should be a routine part of nursing staff training. IMPLICATIONS FOR RESEARCH: Future research should examine the long-term effects of early paternal support on psychosocial, cognitive, and developmental outcomes of NICU infants.

Military parents' perceptions of separation for their younger children.

ABSTRACT: Many studies are available in the literature considering effects of deployment on older school age and adolescent children, but less is known about the effects on younger children. The purpose of this study was to describe the experience of deployment/separation for military children aged 4-10 years from both the deployed parent and stay-at-home parent's experiences. Parents completed demographics followed by an interview to describe the child's reaction to separation. Thematic analysis was used to identify children's reactions and intervention strategies. Thirty-eight families, encompassing 57 children aged 4-10 who experienced a separation or deployment within the past 2 years participated. Interviews included 24 military members and 34 spouses (most frequently the mothers) completed the interview and research instruments. Interview data revealed a turbulent experience for families resulting from frequent and repeated separations. Parents actively employed strategies garnered from military-provided materials and informal interaction with other military parents. The different perspectives provided new insights as to the strategies military families find successful during separations and will be useful in providing anticipatory guidance.

Sexual health needs and psychosocial well-being of patients with prostate cancer in a regional cancer Center.

Prostate cancer is the most common cancer for men. The cancer diagnosis and treatment can affect patients' psychosocial and sexual health. The purpose of this research project was to identify the sexual health concerns of patients with prostate cancer. An anonymous survey was administered to patients while accessing Grand River Regional Cancer Center (GRRCC) that included measures of sexual health and perceived stress and social support, ratings for preferred modes of sexual health programming, and open-ended questions on sexual health and masculinity. Seventy-five patients completed the survey; their mean age was 73.9 years (SD 7.2), the majority were in a couple relationship and identified as heterosexual. The concerns most endorsed were physical changes in sexual functioning and being able to satisfy their partner sexually. These findings can inform sexual health programming and psychosocial oncology for men with prostate cancer.

Trauma Management Therapy and Prolonged Exposure Therapy for PTSD in an active duty sample: Design and methodology of a randomized clinical trial.

Posttraumatic stress disorder (PTSD) resulting from military service is a common, yet often chronic condition. Treatment outcome often is attenuated by programs that are (a) lengthy in nature and (b) constricted in their target outcomes. These limitations leave much of the emotional and behavioral impairment that accompanies PTSD unaddressed and/or unassessed. Typical PTSD treatment programs are 3-4 months in length, which is challenging for the pace of the nation's military. In this investigation, we will compare two treatments, Trauma Management Therapy (TMT) and Prolonged Exposure (PE), both redesigned to address the needs of active duty personnel (300 participants at 3 military installations). Specifically, we will compare the TMT Intensive Outpatient Program (IOP; 3 weeks) to PE's compressed (2 week) format. Both interventions will be compared to a standard course of PE (12 weeks). In addition to PTSD symptomatology, outcome measurement includes other aspects of psychopathology as well as changes in social, occupational, and familial impairment. Potential negative outcomes of massed treatment, such as increased suicidal ideation or increased alcohol use, will be assessed, as will genetic predictors of PTSD subtype and treatment outcome. This study will inform the delivery of care for military-related PTSD and particularly the use of intensive or compressed treatments for active duty personnel.

The Coping Self-Efficacy Scale: Psychometric properties in an outpatient sample of active duty military personnel.

Active duty military service members endure a unique constellation of stressors while deployed or at home. Yet, assessment of protective factors against these stressors among active duty service members represents an under studied area. The present study advances the assessment of protective factors through the psychometric evaluation of the Coping Self-Efficacy Scale (CSES) in a clinical sample of military service members in mental health or substance abuse treatment (n = 200). Cross-sectional data were drawn from military medical records and a supplemental self-report questionnaire. Data extracted included demographic (e.g., sex, age), military characteristics (e.g., rank, years in service), physical health and mental health (e.g., anxiety, depression), and coping self-efficacy. Findings suggest a 3-factor (i.e., problem-focused coping, thought-stopping, and getting social support) CSES structure with acceptable internal consistency. Further, there were small-to-moderate associations with physical and mental health outcomes, providing evidence of construct validity. There were few significant associations with military-related characteristics. Finally, controlling for covariates, thought-stopping beliefs explained unique variance in suicide-related behaviors. Together, findings support the use of the CSES to measure coping-related beliefs in military service members. Recommendations are offered for future research and practice with active duty service members.

Those who died very young-Inferences from δ15 N and δ13 C in bone collagen and the absence of a neonatal line in enamel related to the possible onset of breastfeeding.

OBJECTIVES: Stable isotope analysis has often been used in neonatal remains from archeological contexts to investigate the presence of a signal of breastfeeding and weaning in past populations. Tooth histology on the other hand might be used as an indicator of birth survival. This pilot study aimed to investigate the feasibility of using stable nitrogen (δ15 N) and carbon (δ13 C) isotope values from neonatal bone collagen to elucidate if values deviating from the adult female average could indicate breastfeeding and co-occur with the presence of a neonatal line (NNL). The combination of these independent indicators might be useful in clarifying the fate of individuals who died around birth. MATERIALS AND METHODS: Bone collagen from 21 archeological human and animal specimens was extracted and analyzed via mass-spectrometry for δ15 N and δ13 C. A verification of the stable isotope results was undertaken using tooth histology on three individuals who were investigated for the presence of a NNL as an indicator of live birth and short survival. RESULTS: The biological age of the human samples varied between 8.5 lunar months (Lm) and 2 postnatal months (Pm) of age. All except one individual exhibited elevated δ15 N values compared to the female average. The histological analyses revealed no NNL for this and two further individuals (n = 3). DISCUSSION: The results indicate that elevated nitrogen values of very young infants relative to a female average in archeological contexts are not necessarily associated with a breastfeeding onset signal, and therefore cannot be used exclusively as a proxy of birth survival. The elevation might be possible due to various reasons; one could be nutritional, in particular maternal stress during pregnancy or a metabolic disorder of mother and/or her child. In those cases, the evaluation of a NNL might reveal a false breastfeeding signal as seen for two individuals in our sample who have elevated nitrogen values despite the fact no NNL could be observed. Overall, our data support the growing awareness that bone collagen δ15 N values of neonates/infants should not be used as a proxy for breastfeeding or birth survival on its own.

Improving Perioperative Knowledge, Self-Efficacy, and Performance in Labor and Delivery Nurses: A Quality Improvement Project.

The obstetrical unit utilized a training product (Periop 101: A Core Curriculum OB) to enhance the knowledge, self-efficacy, and performance of nurses circulating for cesarean births. Knowledge was measured using product provided testing. Self-efficacy was assessed using a modified perioperative self-efficacy scale, and performance was evaluated by analyzing documentation accuracy and incident reports. Results demonstrated improvements in perioperative knowledge, self-efficacy, and documentation as well as a reduction in incident reports.

Patient Handoff Processes: Implementation and Effects of Bedside Handoffs, the Teach-Back Method, and Discharge Bundles on an Inpatient Oncology Unit.

BACKGROUND: Bedside handoffs, the teach-back method, and discharge bundles have been shown to contribute to empowering patients to actively engage in their treatment. OBJECTIVES: The objectives were to identify patient activation scores, patient readmission rates, and nursing staff satisfaction before and after implementing bedside handoffs, the teach-back method, and discharge bundles on an inpatient oncology unit at a large military treatment facility. METHODS: A series of three cycles using the Plan-Do-Study-Act framework guided implementation of the multifaceted approach. Patient activation scores, readmission rates, staff satisfaction, and anecdotal feedback from patients and nursing staff were collected prior to and following implementation. FINDINGS: The sample of patients with cancer had high patient activation scores. After implementation of the multifaceted approach, readmission rates decreased from 32% to 25%, and staff satisfaction improved.

Recovery from Mild Traumatic Brain Injury Following Uncomplicated Mounted and Dismounted Blast: A Natural History Approach.

Objective: The purpose of this study is to utilize a natural history approach to describe and understand symptom recovery in personnel diagnosed with a blast-related mild traumatic brain injury (mTBI) resulting from an improvised explosive device blast. Participants and Design: The population included military personnel who experienced a blast mTBI while mounted (vehicle; n = 176) or dismounted (on foot; n = 37) (N = 213). Patients had no co-morbid psychiatric or muscle-skeletal issues and were treated within 72 h of injury. Prevalence and duration of self-reported symptoms were separately analyzed by injury context (mounted vs dismounted). Results: Headache was prominently reported in both mounted (85%) and dismounted (75%) populations. The mean time from injury to return to full duty was between 7.8 d (mounted) and 8.5 d (dismounted). The dismounted population reported visual changes that lasted 0.74 d longer. Conclusion: Our analysis implicates that headache is a common and acutely persistent symptom in mTBI regardless of injury context. Additionally, patients in mounted vs dismounted injury did not report significant differences in symptom prevalence. Although knowing the injury context (i.e., dismounted vs mounted) may be beneficial for providers to understand symptom presentations and deliver accurate anticipatory guidance for patients with blast-related mTBI, no significant differences were observed in this population. This may be due to the population characteristic as the trajectory of recovery may vary for patients who were not able to return to full duty within 30 d or required higher levels of care.

Determining when a fracture occurred: Does the method matter? Analysis of the similarity of three different methods for estimating time since fracture of juvenile long bones.

Radiographic fracture date estimation is a critical component of skeletal trauma analysis in the living. Several timetables have been proposed for how the appearance of radiographic features can be interpreted to provide a likely time frame for fracture occurrence. This study compares three such timetables for pediatric fractures, by Islam et al. (2000), Malone et al. (2011), and Prosser et al. (2012), in order to determine whether the fracture date ranges produced by using these methods are in agreement with one another. Fracture date ranges were estimated for 112 long bone fractures in 96 children aged 1-17 years, using the three different timetables. The extent of similarity of the intervals was tested by statistically comparing the overlap between the ranges. Results showed that none of the methods were in perfect agreement with one another. Differences seen included the size of the estimated date range for when a fracture occurred, and the specific dates given for both the upper and lower ends of the fracture date range. There was greater similarity between the ranges produced by Malone et al. (2011) and both the other two studies than there was between Islam et al. (2000) and Prosser et al. (2012). The greatest similarity existed between Malone et al. (2011) and Islam et al. (2000). The extent of differences between methods can vary widely, depending on the fracture analysed. Using one timetable gives an average earliest possible fracture date of less than 2 days before another, but the range was extreme, with one method estimating minimum time since fracture as 25 days before another method for a given fracture. In most cases, one method gave maximum time since fracture as a week less than the other two methods, but range was extreme and some estimates were nearly two months different. The variability in fracture date estimates given by these timetables indicates that caution should be exercised when estimating the timing of a juvenile fracture if relying solely on one of the published guides. Future research should be undertaken to compare these methods on a population of known fracture timing, and to better understand the relationship between age of the individual, skeletal health, fracture healing rates, and radiographic characteristics of fracture healing.