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Context Quadriceps weakness is associated with disability and aberrant gait biomechanics after anterior cruciate ligament reconstruction (ACLR). Strength-sufficiency cutoff scores, which normalize quadriceps strength to the mass of an individual, can predict who will report better function after ACLR. However, whether gait biomechanics differ between individuals who meet a strength-sufficiency cutoff (strong) and those who do not (weak) remains unknown. Objective To determine whether vertical ground reaction force, knee-flexion angle, and internal knee-extension moment differ throughout the stance phase of walking between individuals with strong and those with weak quadriceps after ACLR. Design Case-control study. Setting Laboratory. Patients or Other Participants Individuals who underwent unilateral ACLR >12 months before testing were dichotomized into strong (n = 31) and weak (n = 116) groups. Main Outcome Measures Maximal isometric quadriceps strength was measured at 90° of knee flexion using an isokinetic dynamometer and normalized to body mass. Individuals who demonstrated maximal isometric quadriceps strength ≥3.0 N·m·kg−1 were considered strong. Three-dimensional gait biomechanics were collected at a self-selected walking speed. Biomechanical data were time normalized to 100% of stance phase. Vertical ground reaction force was normalized to body weight (BW), and knee-extension moment was normalized to BW × height. Pairwise comparison functions were calculated for each outcome to identify between-groups differences for each percentile of stance. Results Vertical ground reaction force was greater in the weak group for the first 22% of stance (peak mean difference [MD] = 6.2% BW) and less in the weak group between 36% and 43% of stance (MD = 1.4% BW). Knee-flexion angle was greater (ie, more flexion) in the strong group between 6% and 52% of stance (MD = 2.3°) and smaller (ie, less flexion) between 68% and 79% of stance (MD = 1.0°). Knee-extension moment was greater in the strong group between 7% and 62% of stance (MD = 0.007 BW × height). Conclusions Individuals with ACLR who generated knee-extension torque ≥3.0 N·m·kg−1 exhibited different biomechanical gait profiles than those who could not. More strength may allow for better energy attenuation after ACLR.

Context Gait biomechanics are linked to biochemical changes that contribute to the development of posttraumatic knee osteoarthritis in individuals with anterior cruciate ligament reconstruction (ACLR). It remains unknown if modifying peak loading during gait using real-time biofeedback will result in acute biochemical changes related to cartilage metabolism. Objective To determine if acutely manipulating peak vertical ground reaction force (vGRF) during gait influences acute changes in serum cartilage oligomeric matrix protein concentration (sCOMP) among individuals with ACLR. Design Crossover study. Patients or Other Participants Thirty individuals with unilateral ACLR participated (70% female, age = 20.43 ± 2.91 years old, body mass index = 24.42 ± 4.25, months post-ACLR = 47.83 ± 26.97). Additionally, we identified a subgroup of participants who demonstrated an increase in sCOMP after the control or natural loading condition (sCOMPCHANGE > 0 ng/mL, n = 22, 70% female, age = 20.32 ± 3.00 years old, body mass index = 24.73 ± 4.33, months post-ACLR = 47.27 ± 29.32). Main Outcome Measure(s) Serum was collected both prior to and immediately after each condition to determine sCOMPchange. Intervention(s) All participants attended 4 sessions that involved 20 minutes of walking on a force-measuring treadmill consisting of a control condition (natural loading) followed by random ordering of 3 loading conditions with real-time biofeedback: (1) symmetric vGRF between limbs, (2) a 5% increase in vGRF (high loading) and (3) a 5% decrease in vGRF (low loading). A general linear mixed model was used to determine differences in sCOMPCHANGE between altered loading conditions and the control group in the entire cohort and the subgroup. Results The sCOMPCHANGE was not different across loading conditions for the entire cohort (F3,29 = 1.34, P = .282). Within the subgroup, sCOMPCHANGE was less during high loading (1.95 ± 24.22 ng/mL, t21 = −3.53, P = .005) and symmetric loading (9.93 ± 21.45 ng/mL, t21 = −2.86, P = .025) compared with the control condition (25.79 ± 21.40 ng/mL). Conclusions Increasing peak vGRF during gait decreased sCOMP in individuals with ACLR who naturally demonstrated an increase in sCOMP after 20 minutes of walking. Trial Registry ClinicalTrials.gov (NCT03035994)

Purpose History of an anterior cruciate ligament reconstruction (ACLR) and high body mass index (BMI) are strong independent risk factors for knee osteoarthritis (KOA) onset. The combination of these risk factors may further negatively affect joint loading and KOA risk. We sought to determine the combined influence of BMI and ACLR on walking speed and gait biomechanics that are hypothesized to influence KOA onset. Methods Walking speed and gait biomechanics (peak vertical ground reaction force [vGRF], peak vGRF instantaneous loading rate [vGRF-LR], peak knee flexion angle, knee flexion excursion [KFE], peak internal knee extension moment [KEM], and peak internal knee abduction moment [KAM]) were collected in 196 individuals with unilateral ACLR and 106 uninjured controls. KFE was measured throughout stance phase, whereas all other gait biomechanics were analyzed during the first 50% of stance phase. A 2 × 2 ANOVA was performed to evaluate the interaction between BMI and ACLR and main effects for both BMI and ACLR on walking speed and gait biomechanics between four cohorts (high BMI ACLR, normal BMI ACLR, high BMI controls, and normal BMI controls). Results History of an ACLR and high BMI influenced slower walking speed (F1,298 = 7.34, P = 0.007), and history of an ACLR and normal BMI influenced greater peak vGRF-LR (F1,298 = 6.56, P = 0.011). When evaluating main effects, individuals with an ACLR demonstrated lesser KFE (F1,298 = 7.85, P = 0.005) and lesser peak KEM (F1,298 = 6.31, P = 0.013), and individuals with high BMI demonstrated lesser peak KAM (F1,297 = 5.83, P = 0.016). Conclusion BMI and history of ACLR together influence walking speed and peak vGRF-LR. History of an ACLR influences KFE and peak KEM, whereas BMI influences peak KAM. BMI may need to be considered when designing interventions aimed at restoring gait biomechanics post-ACLR.

Background: High-quality, representative serological surveys allow direct estimates of immunity profiles to inform vaccination strategies but can be costly and logistically challenging. Leveraging residual serum samples is one way to increase their feasibility.Methods: We subsampled 9,854 residual sera from a 2016 national HIV survey in Zambia and tested these specimens for anti-measles and anti-rubella virus IgG antibodies using indirect enzyme immunoassays. We demonstrate innovative methods for sampling residual sera and analyzing seroprevalence data, as well as the value of seroprevalence estimates to understand and control measles and rubella. Results: National measles and rubella seroprevalence for individuals younger than 50 years was 82·8% (95% CI 81·6, 83·9%) and 74·9% (95% CI 73·7%, 76·0%), respectively. Despite a successful childhood vaccination program, measles immunity gaps persisted across age groups and districts, indicating the need for additional activities to complement routine immunization. Prior to vaccine introduction, we estimated a rubella burden of 96 congenital rubella syndrome cases per 100,000 live births.Conclusion: Residual samples from large-scale surveys can reduce the cost and challenges of conducting serosurveys, and multiple pathogens can be tested. Procedures to access specimen quality, ensure ethical approvals, and link sociodemographic data can improve the timeliness and value of results.

Electric power systems are experiencing a growing number of electronic loads in the residential sector as modern appliance technology progresses, and it has become increasingly more important to consider the total power factor (PF) of residential communities. This paper provides a survey based on literature and publicly available information of typical appliance PF values and effects at the residential level as well as a discussion on appliance energy use and corresponding operation schedules. A procedure for the calculation of equivalent PF is proposed and exemplified with minutely experimental data at 15-minute and hourly time intervals, which correspond to smart metering and traditional practices, respectively. The application of the proposed equivalent PF procedure in coordination with building energy modeling, may, in principle, be employed to determine PF for entire communities at an aggregated level. The paper includes a proposal to simulate reactive power through an approach that utilizes EnergyPlus, a building energy modeling software. Such simulation capability could facilitate improved planning for compensation implementation both in electric power distribution networks and in individual residences, which offers significant opportunity for energy savings.

Context Better knee function is linked to psychological readiness to return to sport after anterior cruciate ligament reconstruction (ACLR). Individuals with ACLR participate in less physical activity than matched uninjured control individuals, yet the association between knee function and physical activity post–ACLR remains unclear. Objective To determine the associations between (1) patient-reported knee function measured using the Knee Injury and Osteoarthritis Outcome Score Knee-Related Quality of Life (KOOS-QOL), daily steps, and minutes spent in moderate-to-vigorous physical activity (MVPA) of individuals with ACLR and (2) KOOS-QOL and daily steps and MVPA in individuals with ACLR who presented with (ie, symptomatic) or without (ie, asymptomatic) clinically meaningful knee-related symptoms. Design Cross-sectional study. Setting Laboratory, free-living conditions. Patients or Other Participants A total of 66 individuals with primary unilateral ACLR (36 women, 30 men; age = 22 ± 4 years, height = 1.71 ± 0.1 m, mass = 71.3 ± 12.6 kg, body mass index = 24.2 ± 2.9, time post–ACLR = 28 ± 33 months). Main Outcome Measure(s) We collected KOOS data and retrospectively stratified participants into those with (symptomatic group, n = 30) or without (asymptomatic group, n = 36) clinically meaningful knee-related symptoms based on previously defined KOOS cutoffs. We assessed daily steps and MVPA using accelerometers that participants wore on the right hip for 7 days. We conducted linear regressions to determine associations between KOOS-QOL and daily steps and MVPA. Results In the entire sample, no associations existed between KOOS-QOL and daily steps (ΔR2 = 0.01, P = .50) or MVPA (ΔR2 = 0.01, P = .36). In the symptomatic group, a greater KOOS-QOL was associated with more time in MVPA (ΔR2 = 0.12, P = .05). In the asymptomatic group, no associations were identified between the KOOS-QOL and daily steps and MVPA. Conclusions Individuals with symptoms post–ACLR who spent more time in MVPA reported higher QOL.

Purpose To compare gait biomechanics throughout stance phase 6 and 12 months after unilateral anterior cruciate ligament reconstruction (ACLR) between ACLR and contralateral limbs and compared with controls. Methods Vertical ground reaction force (vGRF), knee flexion angle (KFA), and internal knee extension moment (KEM) were collected bilaterally 6 and 12 months post-ACLR in 30 individuals (50% female, 22 ± 3 yr, body mass index = 23.8 ± 2.2 kg·m) and at a single time point in 30 matched uninjured controls (50% female, 22 ± 4 yr, body mass index = 23.6 ± 2.1 kg·m). Functional analyses of variance were used to evaluate the effects of limb (ACLR, contralateral, and control) and time (6 and 12 months) on biomechanical outcomes throughout stance. Results Compared with the uninjured controls, the ACLR group demonstrated bilaterally lesser vGRF (ACLR, 9% body weight [BW]; contralateral, 4%BW) during early stance and greater vGRF during midstance (ACLR, 5%BW; contralateral, 4%BW) 6 months post-ACLR. Compared to the uninjured controls, the ACLR group demonstrated bilaterally lesser vGRF (ACLR, 10%BW; contralateral, 8%BW) during early stance and greater vGRF during midstance (ACLR, 5%BW; contralateral, 5%BW) 12 months post-ACLR. Compared with controls, the ACLR limb demonstrated lesser KFA during early stance at 6 (2.3°) and 12 months post-ACLR (2.0°), and the contralateral limb demonstrated lesser KFA during early stance at 12 months post-ACLR (2.8°). Compared with controls, the ACLR limb demonstrated lesser KEM during early stance at both 6 months (0.011BW × height) and 12 months (0.007BW × height) post-ACLR, and the contralateral limb demonstrated lesser KEM during early stance only at 12 months (0.006BW × height). Conclusions Walking biomechanics are altered bilaterally after ACLR. During the first 12 months post-ACLR, both the ACLR and contralateral limbs demonstrate biomechanical differences compared with control limbs. Differences between the contralateral and control limbs increase from 6 to 12 months post-ACLR.

OBJECTIVES To evaluate changes in the femoral cartilage cross-sectional area (CSA) measured with ultrasound (US) between baseline and 1000, 2000, 3000, 4000, and 5000 steps of walking on a treadmill. METHODS Forty-one healthy individuals completed a single testing session. Participants rested with their knees extended on a plinth for 45 minutes to unload the femoral cartilage. Ultrasound was used to acquire images of the femoral cartilage before the treadmill-walking protocol. After the baseline US acquisition, participants walked on a treadmill at their preferred overground walking speed for 1000 steps, after which additional US images of the femoral cartilage were acquired. This process was repeated after 2000, 3000, 4000, and 5000 steps. A 1-way repeated-measures analysis of variance compared the CSA across the 6 step counts. An analysis of variance with repeated measures on time and Bonferroni corrected planned comparisons (.05/5) were used to evaluate differences in the femoral cartilage at each step count compared to baseline. RESULTS The study included 20 male and 21 female participants (mean age ± SD, 21.5 ± 2.8 years; mean body mass index, 24.3 ± 3.4 kg/m 2 ). The CSAs were significantly greater at the 2000-step (1.27 ± 1.75 mm 2 ; P

OBJECTIVE: To compare sagittal walking gait biomechanics between participants with knee osteoarthritis (KOA) who increased quadriceps strength following a lower-extremity strengthening intervention (responders) and those who did not increase strength following the same strengthening protocol (non-responders) both at baseline and following the lower extremity strengthening protocol. DESIGN: Fifty-three participants with radiographic KOA (47% female, 62.3±7.1 years, BMI = 28.5±3.9 kg/m(2)) were enrolled in 10 sessions of lower extremity strengthening over a 28-day period. Maximum isometric quadriceps strength and walking gait biomechanics were collected on the involved limb at baseline and 4-weeks following the strengthening intervention. Responders were classified as individuals who increased quadriceps strength greater than the upper limit of the 95% confidence interval for the minimal detectable change in quadriceps strength (29 Nm) determined in a previous study. 2 × 2 functional analyses of variance were used to evaluate the effects of group (responders and non-responders) and time (baseline and 4-weeks) on time-normalized waveforms for knee flexion angle, vertical ground reaction force (vGRF), and internal knee extension moment. RESULTS: A significant group x time interaction for knee flexion angle demonstrated greater knee flexion angle in the first half of stance at baseline and greater knee extension in the second half of stance at 4-weeks in responders compared to non-responders. There was no significant group x time interaction for vGRF or internal knee extension moment. CONCLUSIONS: Quadriceps strengthening may be used to stimulate small changes in knee flexion angle in individuals with KOA.

Context Individuals with an anterior cruciate ligament reconstruction (ACLR) are at an increased risk of developing posttraumatic osteoarthritis. How osteoarthritis risk factors, such as increased body mass index (BMI), may influence early changes in joint tissue metabolism is unknown. Objective To determine the association between BMI and type 2 cartilage turnover in individuals with an ACLR. Design Cross-sectional study. Setting Research laboratory. Patients or Other Participants Forty-five individuals (31 women, 14 men) with unilateral ACLR at least 6 months earlier who were cleared for unrestricted physical activity. Main Outcome Measure(s) Body mass index (kg/m2) and type 2 collagen turnover were the primary outcomes. Body mass index was calculated from objectively measured height and mass. Serum was obtained to measure type 2 collagen turnover, quantified as the ratio of degradation (collagen type 2 cleavage product [C2C]) to synthesis (collagen type 2 C-propeptide [CP2]; C2C : CP2). Covariate measures were physical activity level before ACLR (Tegner score) and current level of disability (International Knee Documentation Committee Index score). Associations of primary outcomes were analyzed for the group as a whole and then separately for males and females. Results Overall, greater BMI was associated with greater C2C : CP2 (r = 0.32, P = .030). After controlling for covariates (Tegner and International Knee Documentation Committee Index scores), we identified a similar association between BMI and C2C : CP2 (partial r = 0.42, P = .009). Among women, greater BMI was associated with greater C2C : CP2 before (r = 0.47, P = .008) and after (partial r = 0.50, P = .008) controlling for covariates. No such association occurred in men. Conclusions Greater BMI may influence greater type 2 collagen turnover in those with ACLR. Individuals, especially women, who maintain or reduce BMI may be less likely to demonstrate greater type 2 collagen turnover ratios after ACLR.

Consumer cost-sharing has been shown to diminish utilization of preventive services. Recent efforts, including provisions within the Affordable Care Act, have sought to increase use of preventive care through elimination of cost-sharing for clinically indicated services. We conducted a rapid review of the literature to determine the impact of cost-share elimination on utilization of preventive services. Searches were conducted in PubMed, Scopus, and CINAHL Complete databases as well as in grey literature. A total of 35 articles were included in qualitative synthesis and findings were summarized for three clinical service categories: cancer screenings, contraceptives, and additional services. Impacts of cost-sharing elimination varied depending on clinical service, with a majority of findings showing increases in use. Studies that included socioeconomic status reported that those who were financially vulnerable incurred substantial increases in utilization. Future investigations on additional clinical services are warranted as is research to better elucidate populations who most benefit from cost-sharing elimination.

Antenatal care (ANC) provides a platform to counsel pregnant women on maternal nutrition and to prepare the mother to breastfeed. Recent reviews suggest that gaps in the coverage and quality of counselling during pregnancy may partly explain why services do not consistently translate to improved behavioural outcomes in South Asia. This scoping literature review collates evidence on the coverage and quality of counselling on maternal nutrition and infant feeding during ANC in five South Asian countries and the effectiveness of approaches to improve the quality of counselling. Coverage data were extracted from the most recent national surveys, and a scoping review of peer‐reviewed and grey literature (1990–2019) was conducted. Only Afghanistan and Pakistan have survey data on the coverage of counselling on both maternal nutrition and breastfeeding, nine studies described the quality of counselling and three studies assessed the effectiveness of interventions to improve the quality of services. This limited body of evidence suggests that inequalities in access to services, gaps in capacity building opportunities for frontline workers and the short duration and frequency of counselling contracts constrain quality, while the format, duration, frequency and content of health worker training, together with supportive supervision, are probable approaches to improve quality. Greater attention is needed to integrate indicators into monitoring and supervision mechanisms, periodic surveys and programme evaluations to assess the status of and track progress in improving quality and to build accountability for quality counselling, while research is needed to understand how best to assess and strengthen quality in specific settings.

Background Abdominal wall hernia is a common surgical condition. Patients may present in an emergency with bowel obstruction, incarceration or strangulation. Small bowel obstruction (SBO) is a serious surgical condition associated with significant morbidity. The aim of this study was to describe current management and outcomes of patients with obstructed hernia in the UK as identified in the National Audit of Small Bowel Obstruction (NASBO). Methods NASBO collated data on adults treated for SBO at 131 UK hospitals between January and March 2017. Those with obstruction due to abdominal wall hernia were included in this study. Demographics, co‐morbidity, imaging, operative treatment, and in‐hospital outcomes were recorded. Modelling for factors associated with mortality and complications was undertaken using Cox proportional hazards and multivariable regression modelling. Results NASBO included 2341 patients, of whom 415 (17·7 per cent) had SBO due to hernia. Surgery was performed in 312 (75·2 per cent) of the 415 patients; small bowel resection was required in 198 (63·5 per cent) of these operations. Non‐operative management was reported in 35 (54 per cent) of 65 patients with a parastomal hernia and in 34 (32·1 per cent) of 106 patients with an incisional hernia. The in‐hospital mortality rate was 9·4 per cent (39 of 415), and was highest in patients with a groin hernia (11·1 per cent, 17 of 153). Complications were common, including lower respiratory tract infection in 16·3 per cent of patients with a groin hernia. Increased age was associated with an increased risk of death (hazard ratio 1·05, 95 per cent c.i. 1·01 to 1·10; P = 0·009) and complications (odds ratio 1·05, 95 per cent c.i. 1·02 to 1·09; P = 0·001). Conclusion NASBO has highlighted poor outcomes for patients with SBO due to hernia, highlighting the need for quality improvement initiatives in this group., This study shows that small bowel obstruction due to abdominal wall hernia is common, typically involves a co‐morbid group of patients and has poor outcomes, including high mortality rates. High mortality from this problem

Objectives: Individuals with an anterior cruciate ligament (ACL) injury are at high risk of developing posttraumatic osteoarthritis (PTOA). A comprehensive study is needed to determine the time course of joint tissue metabolic changes occurring following ACL injury and reconstruction (ACLR). The purpose of this longitudinal nested comparison-control study was to simultaneously evaluate serum biomarkers of inflammation and cartilage matrix damage in ACL injured patients prior to ACLR and 6 and 12 months post-ACLR, as well as in matched uninjured controls. Methods: Serum was collected from 34 ACL injured individuals (53% female, 20.7±2.4 years old, 24.2±4.1 body mass index [BMI]) within 14 days of primary ACL injury (baseline), as well as at 6 and 12 months following bone-patellar-tendon-bone autograft ACLR. Serum was also collected from 34 uninjured matched controls (53% Female, 20.5±2.4 years old, 24.1±3.5 BMI) at a single timepoint. Blood was collected from the antecubital fossa, centrifuged and stored at -80°C prior to batch analysis. Commercial enzyme-linked immunosorbent assays were used to evaluate concentrations of: 1) a pro-inflammatory cytokine [Monocyte Chemoattractant Protein; MCP-1]; 2) a matrix degrading enzyme [matrix metalloproteinase-3; MMP-3]; 3) a cartilage breakdown biomarker [cartilage oligomeric matrix protein; COMP]; and type-II collagen turnover [type-II collagen cleavage: synthesis; C2C:CPII]. Separate Bonferroni-corrected independent t-tests were used to determine differences between the ACL injured group at each timepoint and uninjured controls for each biomarker (P ≤ 0.015). Similarly, separate Bonferroni-corrected dependent t-tests were used to determine differences in biomarker concentrations over time for the ACLR group. Results: Serum concentrations of MCP-1 and COMP were greater in the ACL injured individuals at all timepoints compared to the controls (P ≤ 0.015, Table 1), yet no differences were found over time in the ACL injured group. MMP-3 concentrations increased between baseline and 6 months post-ACLR (P ≤ 0.015, see Table), yet no differences were found between 6 and 12 months post-ACLR, between baseline and 12 months, or between ACLR and controls at any of the time points. C2C:CPII was not different between ACL injured individuals and controls at baseline or 6 months post-ACLR. C2C:CPII was significantly increased between 6 and 12 months-post ACLR, and was found to be greater than baseline and greater than controls at 12 months post-ACLR (P ≤ 0.015, see Table). Conclusion: Our study is critical in demonstrating the time course of multiple joint tissue metabolic changes following ACL injury and ACLR. Elevated serum MCP-1 and COMP concentrations, linked to early deleterious metabolic processes associated with PTOA development, are evident soon after ACL injury and persist at 12 months post-ACLR. Serum MMP-3 concentrations were elevated 6 months post-ACLR compared to the baseline measurements, suggesting factors occurring after ACLR initiate upregulation of matrix degrading enzymes. Furthermore, elevated C2C:CPII occurs within the first 12 months post ACLR but not until after the 6-month post-ACLR timepoint. Further studies are needed to determine how long these joint tissue metabolic changes persist after ACL injury and ACLR, as well as how joint tissue metabolism is affected by the type and timing of different surgical and nonsurgical treatments.

Biofeedback has recently been explored to target deviant lower extremity loading mechanics following anterior cruciate ligament reconstruction (ACLR) to mitigate the development of post traumatic osteoarthritis. The impact this feedback has on the structure of the stride interval dynamics—a barometer of gait system health—however, have yet to be examined. This study was designed to assess how feedback, used to alter lower-extremity loading during gait, affects the structure of stride interval variability by examining long-range stride-to-stride correlations during gait in those with unilateral ACLR. Twelve participants walked under three separate loading conditions: (1) control (i.e., no cue) (2) high loading, and (3) low loading. Baseline vertical ground reaction force (vGRF) data was used to calculate a target 5% change in vGRF for the appropriate loading condition (i.e., high loading was +5% vGRF, low loading was −5% vGRF). The target for the load condition was displayed on a screen along with real-time vGRF values, prescribing changes in stride-to-stride peak vertical ground reaction forces of each limb. From time-series of stride intervals (i.e., duration), we analyzed the mean and standard deviation of stride-to-stride variability and, via detrended fluctuation analysis (i.e., DFA α), temporal persistence for each feedback condition. Both the high and low loading conditions exhibited a change toward more temporally persistent stride intervals (high loading: α =0.92, low loading: α = 0.98) than walking under the control condition (α = 0.78; high vs. control: p = .026, low vs. control: p = .001). Overall, these results indicate that altering lower extremity load changes the temporal persistence of the stride internal dynamics in ACLR individuals, demonstrating the implications of the design of gait training interventions and the influence feedback has on movement strategies.

Transcutaneous electrical nerve stimulation (TENS) facilitates quadriceps voluntary activation in experimental settings. Augmenting therapeutic exercise (TE) with TENS may enhance the benefits of TE in individuals with knee osteoarthritis (KOA) and quadriceps voluntary activation failure (QVAF). PURPOSE This study aimed to determine the effect of TENS + TE on patient-reported function, quadriceps strength, and voluntary activation, as well as physical performance compared with sham TENS + TE (Sham) and TE alone in individuals with symptomatic KOA and QVAF. METHODS Ninety individuals participated in a double-blinded randomized controlled trial. Everyone received 10 standardized TE sessions of physical therapy. TENS + TE and Sham groups applied the respective devices during all TE sessions and throughout activities of daily living over 4 wk. The Western Ontario and McMaster University Osteoarthritis Index (WOMAC), quadriceps strength, and voluntary activation, as well as a 20-m walk test, chair-stand test, and stair-climb test were performed at baseline, after the 4-wk intervention (post 1) and at 8 wk after the start of the intervention (post 2). Mixed-effects models were used to determine between-group differences between baseline and post 1, as well as baseline and post 2. RESULTS Improvements in WOMAC subscales, quadriceps strength, and voluntary activation, 20-m walk times, chair-stand repetitions, and stair-climb time were found at post 1 and post 2 compared with baseline for all groups (P < 0.05). WOMAC Pain and Stiffness improved in the TENS + TE group compared with TE alone at post 1 (P < 0.05); yet, no other between-group differences were found. CONCLUSIONS TE effectively improved patient-reported function, quadriceps strength, and voluntary activation, as well as physical performance in individuals with symptomatic KOA and QVAF, but augmenting TE with TENS did not improve the benefits of TE.

Context Developing osteoarthritis is common after anterior cruciate ligament reconstruction (ACLR). Monitoring changes in femoral cartilage size after ACLR may be a way to detect the earliest structural alterations before the radiographic onset of osteoarthritis. Diagnostic ultrasonography (US) offers a clinically accessible and valid method for evaluating anterior femoral cartilage size. Objective To compare the US measurements of anterior femoral cross-sectional area and cartilage thickness between limbs in individuals with a unilateral ACLR and between the ACLR limbs of these individuals and the limbs of uninjured control participants. Design Case-control study. Setting Research laboratory. Patients or Other Participants A total of 20 volunteers with an ACLR (37.0 ± 26.6 months after surgery) and 28 uninjured volunteers. Main Outcome Measure(s) We used US to assess anterior femoral cartilage cross-sectional area and thickness (ie, medial, lateral, and intercondylar) in the ACLR and contralateral limbs of participants with ACLR and unilaterally in the reference limbs of uninjured participants. Results The ACLR limb presented with greater anterior femoral cartilage cross-sectional area (96.68 ± 22.68 mm2) than both the contralateral (85.69 ± 17.57 mm2, t19 = 4.47; P < .001) and uninjured (84.62 ± 15.89 mm2, t46 = 2.17; P = .04) limbs. The ACLR limb presented with greater medial condyle thickness (2.61 ± 0.61 mm) than both the contralateral (2.36 ± 0.47 mm, t19 = 2.78; P = .01) and uninjured limbs (2.22 ± 0.40 mm, t46 = 2.69; P = .01) and greater lateral condyle thickness (2.46 ± 0.65 mm) than the uninjured limb (2.12 ± 0.41 mm, t46 = 2.20; P = .03). Conclusions Anterior femoral cartilage cross-sectional area and thickness assessed via US were greater in the ACLR limb than in the contralateral and uninjured limbs. Greater thickness and cross-sectional area may have been due to cartilage swelling or hypertrophy after ACLR, which may affect the long-term health of the joint.

The study sought to determine the association between gait biomechanics (vertical ground reaction force [vGRF], vGRF loading rate [vGRF-LR]) collected 6 months following anterior cruciate ligament reconstruction (ACLR) with patient-reported outcomes at 12 months following ACLR. Walking gait biomechanics and all subsections of the Knee Injury and Osteoarthritis Outcomes Score (KOOS) were collected at 6 and 12 months following ACLR, respectively, in 25 individuals with a unilateral ACLR. Peak vGRF and peak instantaneous vGRF-LR were extracted from the first 50% of the stance phase. Limb symmetry indices (LSI) were used to normalize outcomes in the ACLR limb to that of the uninjured limb (ACLR/uninjured). Linear regression analyses were used to determine associations between biomechanical outcomes and KOOS while accounting for walking speed. Receiver operator characteristic curves were used to determine the accuracy of 6-month biomechanical outcomes for identifying individuals with acceptable patient-reported outcomes, using previously defined KOOS cut-off scores, 12 months post-ACLR. Individuals with lower peak vGRF LSI 6 months post-ACLR demonstrated worse patient-reported outcomes (KOOS Pain, Activities of Daily life, Sport and Recreation, Quality of Life) at the 12-month exam. A peak vGRF LSI ≥0.99 6 months following ACLR associated with 13.33× higher odds of reporting acceptable patient-reported outcomes 12 months post-ACLR. Lesser peak vGRF LSI during walking at 6-months post-ACLR may be a critical indicator of worse future patient-reported outcomes. Clinical significance achieving early symmetrical lower extremity loading and minimizing under-loading of the ACLR limb during walking may be a potential therapeutic target for improving patient-reported outcomes post-ACLR. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2932-2940, 2018.

Low bone mineral density (BMD) is a significant comorbidity in Alzheimer's disease (AD) and may reflect systemic regulatory pathway dysfunction. Low BMD has been identified in several AD mouse models selective for amyloid-β or tau pathology, but these deficits were attributed to diverse mechanisms. In this study, we identified common pathophysiological mechanisms accounting for bone loss and neurodegeneration in the htau mouse, a tauopathy model with an early low BMD phenotype. We investigated the Wnt/β-catenin pathway—a cellular signaling cascade linked to both bone loss and neuropathology. We showed that low BMD persisted in male htau mice aged from 6 to 14 months, remaining significantly lower than tau-null and C57BL/6J controls. Osteogenic gene expression in female and male htau mice was markedly reduced from controls, indicating impaired bone remodeling. In both the bone and brain, htau mice showed alterations in Wnt/β-catenin signaling genes suggestive of increased inhibition of this pathway. These findings implicate dysfunctional Wnt signaling as a potential target for addressing bone loss in AD.

Habitual walking speed is a key functional outcome that has implications for knee biomechanics that occur during gait. Lower extremity biomechanics during walking affects the loading of the femoral cartilage. Ultrasonography (US) can be used to assess resting femoral cartilage thickness and acute cartilage deformation in response to walking. The purpose of this study was to determine the association between habitual walking speed and both resting femoral cartilage thickness and deformation. Twenty-four healthy participants with no history of knee injury volunteered for this study. Habitual walking speed was assessed with a 20-m walk test. Femoral cartilage thickness was assessed with US in the medial condyle, lateral condyle, and intercondylar regions prior to and immediately following 30 min of walking. Femoral cartilage deformation was calculated as the percent change in cartilage thickness acutely following the walking protocol. Separate Pearson product moment correlations were used to assess the association between habitual walking speed and each US cartilage variable. Slower habitual walking speed was significantly associated with greater medial femoral cartilage deformation (r = 0.48, P = 0.018), but not with lateral and intercondylar deformation. Habitual walking speed was not significantly associated with the resting cartilage thickness in any cartilage region. These findings highlight the in vivo association between walking speed and medial femoral cartilage deformation. When controlling for body mass index, the association between walking speed and medial cartilage deformation was weakened (Δr = −0.12). Future studies are needed to determine the extent to which BMI influences the association between walking speed and cartilage deformation.

Individuals with an anterior cruciate ligament reconstruction (ACLR) are susceptible to persistent disability, weight gain and the development of knee osteoarthritis. It remains unclear whether body mass index (BMI) is a factor that influences disability following ACLR. The purpose of this study was to determine the association between BMI and self-reported disability [International Knee Documentation Committee (IKDC) Index] in individuals with a unilateral ACLR. We hypothesized that lower BMI would associate with higher IKDC. BMI and IKDC were measured in 668 individuals with a unilateral ACLR (60.9% female, BMI 24.4 ± 3.7 kg/m2, IKDC 84.7 ± 11.9%). Bivariate associations were conducted between BMI and IKDC for the entire sample and selected subsets (gender, ACLR graft type and history of meniscal injury). Multiple regression analyses were used to determine the impact of potential covariates (Tegner score, age and months since ACLR) for significant bivariate associations. After accounting for covariates, there were no significant associations between BMI and IKDC when separately evaluating the cohort based on either gender or history of a concomitant meniscal injury. The odds of achieving age- and gender-matched healthy population average IKDC scores for those with low ( 0.001, n.s.) after accounting for covariates. BMI uniquely predicted a significant but negligible amount of variance in IKDC in individuals with a patellar tendon autograft (ΔR 2 = 0.015, n.s.). Individuals with low BMI demonstrated higher odds (odds ratio = 1.45; 1.05–1.99) of achieving population average IKDC scores compared to participants with high BMI. There was a significant but negligible correlation between lower BMI and lesser disability in individuals with unilateral ACLR and individuals who are underweight or of normal BMI demonstrated higher odds of achieving population average IKDC scores compared to overweight or obese individuals. While an overall association was found between lower BMI and lesser disability, the magnitude of the association remains negligible; therefore, BMI was not a strong clinical predictor of successful ACLR outcomes in this cohort of patients with unilateral ACLR. Cross-sectional prognostic study, Level II.

Summary Objective To determine the magnitude of medial femoral cartilage deformation using ultrasonography (US) following walking and running in healthy individuals. Design Twenty-five healthy participants with no history of osteoarthritis or knee injury volunteered for this study. Medial femoral cartilage thickness was assessed using US before and after three separate 30-min loading conditions: (1) walking at a self-selected speed, (2) running at a self-selected speed, and (3) sitting on a treatment table (i.e., control). Cartilage deformation was calculated as the percent change score from pre to post loading in each loading condition. The magnitude of cartilage deformation was compared between the three loading conditions. Results There was no difference in baseline cartilage thickness between the three sessions ( F 1,24 = 0.18, P = 0.68). Cartilage deformation was different between the loading conditions ( F 1,24 = 47.54, P t 24 = 6.90, P d = −1.92) and running (%Δ = −8.9, t 24 = 8.14, P d = −1.85) conditions resulted in greater cartilage deformation when compared to the control condition (%Δ = +3.4). There was no difference in cartilage deformation between the running and walking conditions ( t 24 = 1.10, P = 0.28, d = 0.33). US measured medial femoral cartilage thickness demonstrated reliability and precision within a single session (ICC 2,k = 0.966, SEM = 0.07 mm) and between additional sessions separated by seven (ICC 2,k = 0.964, SEM = 0.08 mm) and 16 days (ICC 2,k = 0.919, SEM = 0.11 mm). Conclusions US demonstrated to be a reliable and sensitive imaging modality at quantifying medial femoral cartilage deformation in healthy individuals. Both walking and running conditions created greater cartilage deformation when compared to the control conditions, but no difference was observed between the walking and running conditions.

Background/objective The purpose of this cross-sectional study was to determine associations between body composition, self-reported function, and physical performance after accounting for body mass index (BMI) in individuals with knee osteoarthritis. Methods Percent fat and lean mass were evaluated using dual energy x-ray absorptiometry. Self-reported function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] function subscale) and physical performance (20-m walk, chair stand, and stair climb) were collected on 46 adults (30% male; BMI, 29.6 ± 3.8 kg/m) with radiographically defined knee osteoarthritis (Kellgren-Lawrence grades 2-4). Linear regressions determined the unique association between WOMAC and physical performance explained individually by percent fat and lean mass ([INCREMENT]R) after accounting for BMI. Results Lower percent fat mass significantly associated with better physical performance after accounting for BMI (20-m walk: [INCREMENT]R = 0.10, p = 0.03; chair stand: [INCREMENT]R = 0.16, p = 0.01; stair climb: [INCREMENT]R = 0.11, p = 0.03). Higher percent lean mass significantly associated with better chair stand ([INCREMENT]R = 0.09, p = 0.04) but not 20-m walk or stair climb ([INCREMENT]R range, 0.04-0.07, p > 0.05). After accounting for BMI, neither percent fat nor lean mass associated with WOMAC. Body mass index did not significantly associate with WOMAC or physical performance. Conclusions Lower percent fat and higher percent lean mass associated with better physical performance after accounting for BMI. Body composition and BMI may be used together in the future to more comprehensively understand the association between obesity and disability.

Most children in South Asia are breastfed at some point in their lives; however, many are not breastfed optimally, including the early initiation of breastfeeding (EIBF) within 1 hr of birth, avoidance of prelacteal feeds (APF), exclusive breastfeeding (EBF) for 6 months, and continued breastfeeding (CBF) up to 2 years of age or beyond. This review identifies and collates evidence on the effectiveness of interventions to support optimal breastfeeding in five countries in South Asia: Afghanistan, Bangladesh, India, Nepal, and Pakistan. A scoping review was conducted of peer‐reviewed and grey literature. The 31 eligible studies included randomized trials and quasi‐experimental designs that were conducted between 1990 and 2015. Data were collated regarding intervention design, characteristics, and effectiveness to support EIBF, APF, EBF, and CBF. Most studies reported a positive impact on breastfeeding outcomes, including 21/25 studies that examined EIBF, 15/19 studies that examined EBF, and 10/10 studies that examined APF. The only study that examined CBF reported no effect. Education, counselling, and maternal, newborn, and child health initiatives were common intervention types with positive effects on breastfeeding outcomes. Interventions were delivered in health facility, community, and home/family environments. Programmes and interventions that reached women and their families with repeated exposure and beginning during pregnancy were more likely to improve EIBF and EBF outcomes. Interventions with no impact on breastfeeding were characterized by short duration, irregular frequency, inappropriate timing, poor coverage, and targeting.

Optimal breastfeeding practices, including early initiation of breastfeeding (EIBF) within 1 hr of birth, exclusive breastfeeding (EBF) for the first 6 months of age, and continued breastfeeding (CBF) for 2 years of age or beyond with appropriate complementary foods, are essential for child survival, growth, and development. Breastfeeding norms differ within and between countries in South Asia, and evidence is needed to inform actions to protect, promote, and support optimal practices. This study examines time trends and predictors of EIBF, avoidance of prelacteal feeding (APF), EBF, and CBF to 2 years using survey data from Afghanistan, Bangladesh, India, Nepal, and Pakistan since 1990. EIBF, APF, and EBF increased in Bangladesh, India, and Nepal from 1990 to 2016. EIBF and EBF increased in Pakistan from 1990 to 2013, but both EIBF and APF decreased in recent years. In Afghanistan, EIBF, APF, and EBF decreased from 2010 to 2015. CBF remained fairly constant across the region although prevalence varied by country. Significant (p

Background Declines in the ability to rapidly generate quadriceps muscle torque may underlie disability in individuals with tibiofemoral osteoarthritis. Objective To determine whether quadriceps rate of torque development (RTD) predicts self-reported disability and physical performance outcomes in individuals with tibiofemoral osteoarthritis. Methods This controlled laboratory, cross-sectional study assessed quadriceps strength and RTD in 76 individuals (55% female; mean ± SD age, 61.83 ± 7.11 years) with symptomatic and radiographic tibiofemoral osteoarthritis. Early (0-50 milliseconds), late (100-200 milliseconds), and overall peak RTDs were quantified in the symptomatic (involved) and contralateral limbs and used to calculate bilateral average values. Disability was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function subscale and 3 physical performance tests, including the (1) 20-m fast-paced walk, (2) 30-second chair stand, and (3) timed stair climb. Separate univariate regression models were used to determine the unique associations among measures of quadriceps RTD, WOMAC function score, and physical performance outcomes after accounting for quadriceps strength (change in R2). Results Greater involved-side late RTD and greater bilateral average early RTD were associated with faster walking (change in R2 = 0.05, P = .013 and change in R2 = 0.05, P = .043, respectively). Greater bilateral average late RTD was associated with faster walking (change in R2 = 0.20, P

Objective: The objective of this study was to profile over a 24 h period the prolactin responses of exercise-trained men on a day involving rest with no exercise in comparison to a day involving exercise training sessions. Methods: This is a quasi-experimental design study using repeated measures determination of 24 h prolactin responses in exercise-trained men ( n = 16; age = 27.3± 3.3 years (mean ± standard deviation)). Blood samples were taken hourly over a 24 h period on a day involving two intensive exercise training sessions (ED), and on a separate control day (CD) with no exercise activity. The order of the ED and CD was randomized. Physical activity and diet were controlled and replicated for the ED and CD. Blood specimens were handled, prepared and analyzed utilizing appropriate standard clinical practices. The data were analyzed with the Friedman analysis of variance and Nemenyi post hoc statistical procedure for repeated measures. Results: On the CD, prolactin displayed a typical circadian rhythm with daytime values of the hormone being less than the nocturnal rise once sleep had begun ( p < 0.05; 16:00–20:00 h > all other times). On the ED, prolactin responses were noticeably different from those of the CD. The morning and afternoon exercise sessions included significant increases in prolactin immediately at the end of the exercise sessions, being greater than corresponding CD time points ( p < 0.01; 01:00 h and 10:00 h); also for the second hour (2 h) following the morning exercise session. On the ED there was a displayed circadian nocturnal response in the hormone with 16:00–24:00 h being elevated above the all nonexercise effected values for that specific day ( p < 0.01). Finally, the ED nocturnal elevation for prolactin for 16:00–24:00 h was significantly greater than the same respective hours on the CD ( p < 0.05). Conclusion: Findings clearly demonstrated that nocturnal prolactin responses are augmented in exercise-trained men on days when they perform exercise. The mechanisms inducing this adaptive response are unclear but warrant further investigation.

BACKGROUND Increased exposure to a broad array of pathogens in children residing in sub-Saharan Africa may lead to heightened immune activation and increased proportions of memory T cells. Changes in the size of these cellular subsets have implications for restoration of normal immune function after treatment with highly active antiretroviral therapy (HAART) and are not well characterized in young sub-Saharan African children. METHODS CD4⁺ and CD8⁺ T-cell subsets were measured by flow cytometry in 157 HIV-infected Zambian children before and at 3-month intervals during HAART for up to 30 months and in 34 control children at a single study visit. RESULTS Before HAART, HIV-infected children had higher levels of activated and effector memory (EM) CD4⁺ and CD8⁺ T cells, and lower levels of naive T cells and CD8⁺ T cells expressing IL-7Rα, compared with control children. The median duration of follow-up was 14.9 months (interquartile range, 6.4-23.2) among 120 HIV-infected children with at least 1 study follow-up visit. Levels of immune activation and EM CD4⁺ T cells declined within 6 months of HAART, but the percentages of EM CD4 T cells and effector CD8⁺ T cells remained elevated through 30 months of HAART. IL-7Rα-expressing CD8⁺ T cells increased with HAART, suggesting expansion of memory capacity. CONCLUSIONS HAART significantly reduced levels of immune activation and EM CD4⁺ T cells, and promoted reconstitution of naive T cells and IL-7Rα-expressing CD8⁺ T cells. However, persistently high levels of EM CD4⁺ T cells in HIV-infected children may reflect chronic perturbations in T-cell subset composition.

Background Antiretroviral therapy (ART) is associated with incomplete restoration of resting memory B (RMB) cell percentages in adults infected with HIV, but the effects on RMB cells in children are less well defined, in part because changes in RMB cell percentages are confounded by the development and maturation of the RMB cell pool. The objective of this study was to assess the effect of age at ART initiation on RMB cell percentages over time in HIV-infected Zambian children. Methods RMB cell percentages (CD19CD21CD27) were measured by flow cytometry in 146 HIV-infected Zambian children (9-120 months old) at baseline and at 3-month intervals after ART initiation and in 34 control children at a single study visit. Results RMB cell percentages among untreated HIV-infected children younger than 24 months did not differ from those of control children (P = 0.97). Among HIV-infected children older than 24 months of age, however, each 12-month increase in age at ART initiation was associated with a 1.8% decrease in RMB cell percentage. In contrast, RMB cell percentages in control children up to 48 months increased 4.4% with each 12-month increase in age. After 12 months of ART, children aged 24-60 months had a significant increase in RMB cell percentages that no longer differed from those of control children. Conclusions Initiation of ART in 2- to 5-year-old HIV-infected children resulted in reconstitution of RMB cell percentages to levels similar to control children and may help restore normal development and maintenance of B-cell immunity.

Background. In 2010, Zambia had a large measles outbreak, providing an opportunity to measure changes in measles serostatus following highly active antiretroviral therapy (HAART), exposure to measles virus, and revaccination among children infected with human immunodeficiency virus (HIV). Methods. A prospective cohort study of 169 HIV-infected Zambian children aged 9–60 months with a history of measles vaccination was conducted to characterize the effects of HAART and revaccination on measles immunoglobulin G (IgG) serostatus by enzyme immunoassay. Results. Prior to the measles outbreak, only 23% of HIV-infected children were measles IgG seropositive at HAART initiation. After adjusting for 6-month changes in baseline age and 5% changes in nadir CD4+ T-cell percentage, HAART was not associated with measles IgG seroconversion. However, 18 of 19 children seroconverted after revaccination. Eight children seroconverted during the outbreak without revaccination and were likely exposed to wild-type measles virus, but none were reported to have had clinical measles. Conclusions. Immune reconstitution after HAART initiation did not restore protective levels of measles IgG antibodies, but almost all children developed protective antibody levels after revaccination. Some previously vaccinated HIV-infected children had serological evidence of exposure to wild-type measles virus without a reported history of measles.

To explore immunologic risk factors for death within 90 days of highly active antiretroviral therapy (HAART) initiation, CD4(+) and CD8(+) T cell subsets were measured by flow cytometry and characterized by logistic regression in 149 Zambian children between 9 months and 10 years of age enrolled in a prospective, observational study of the impact of HAART on measles immunity. Of 21 children who died during follow-up, 17 (81%) had known dates of death and 16 (76%) died within 90 days of initiating HAART. Young age and low weight-for-age z-scores were associated with increased risks of mortality within 90 days of starting HAART, whereas CD4(+) T cell percentage was not associated with mortality. After adjusting for these factors, each 10% increase in CD8(+) effector T cells increased the odds of overall mortality [OR=1.43 (95% CI: 1.08, 1.90)] and was marginally associated with early mortality [OR=1.29 (95% CI: 0.97, 1.72)]. Conversely, each 10% increase in CD4(+) central memory T cells decreased the odds of overall [OR=0.06 (95% CI: 0.01, 0.59)] and early mortality [OR=0.09 (95% CI: 0.01, 0.97)]. Logistic regression prediction models demonstrated areas under the receiver-operator characteristic curves of ≥85% for early and overall mortality, with bootstrapped sensitivities of 82-85% upon validation, supporting the predictive accuracy of the models. CD4(+) and CD8(+) T cell subsets may be more accurate predictors of early mortality than CD4(+) T cell percentages and could be used to identify children who would benefit from more frequent clinical monitoring after initiating HAART.

This chapter provides an overview of the hypothalamic–pituitary–ovarian (HPO) axis, otherwise known as the female reproductive axis. The HPO axis is the major regulator of the female reproductive hormones: estrogen and progesterone. Gonadotropin-releasing hormone is released from the hypothalamus at the onset of puberty in young women, and induces the release of luteinizing hormone (LH) and follicular stimulating hormone (FSH) from the anterior pituitary. These two hormones bind to ovarian receptors and signal the release of estrogen and progesterone. Estrogen and progesterone are released in fluctuating concentrations throughout the menstrual cycle, resulting in the follicular (low estrogen) phase and the luteal (high estrogen) phase. These phases are separated by ovulation and end with either fertilization or menstruation in a eumenorrheic woman.

This chapter addresses what is known about the endocrine system components growth hormone (GH)-insulin-like growth factor (IGF) axis, thyroid axis, and prolactin relative to exercise and exercise training. Each one of these hormone axes contributes to the maintenance of homeostasis in the body through impact on a multitude of physiological systems. The homeostatic disruption of exercise causes differing responses in each hormone axis. GH levels increase with sufficient stimulation, and IGFs are released in response to GH from the anterior pituitary providing multiple roles including anabolic properties. Changes in the thyroid hormones T3 and T4 vary greatly with exercise, from increases/decreases to no change in levels across different exercise types, intensities and durations. These ambiguous findings could be due to numerous confounding factors (e.g. nutrition status) within the research. Prolactin increases proportionally to the intensity of the exercise. The magnitude may be augmented with extended durations; conflicting findings have been reported with resistance training. While the responses to exercise vary, it appears there may be overall adaptive and regenerative impacts on the body into recovery by these hormones through immune and tissue inflammatory responses/mediations. Nonetheless, well-designed exercise research studies are still needed on each of these hormones, especially thyroid hormones and prolactin.

SummaryBackgroundIf carotid artery narrowing remains asymptomatic (ie, has caused no recent stroke or other neurological symptoms), successful carotid endarterectomy (CEA) reduces stroke incidence for some years. We assessed the long-term effects of successful CEA.MethodsBetween 1993 and 2003, 3120 asymptomatic patients from 126 centres in 30 countries were allocated equally, by blinded minimised randomisation, to immediate CEA (median delay 1 month, IQR 0·3–2·5) or to indefinite deferral of any carotid procedure, and were followed up until death or for a median among survivors of 9 years (IQR 6–11). The primary outcomes were perioperative mortality and morbidity (death or stroke within 30 days) and non-perioperative stroke. Kaplan-Meier percentages and logrank p values are from intention-to-treat analyses. This study is registered, number ISRCTN26156392.Findings1560 patients were allocated immediate CEA versus 1560 allocated deferral of any carotid procedure. The proportions operated on while still asymptomatic were 89·7% versus 4·8% at 1 year (and 92·1% vs 16·5% at 5 years). Perioperative risk of stroke or death within 30 days was 3·0% (95% CI 2·4–3·9; 26 non-disabling strokes plus 34 disabling or fatal perioperative events in 1979 CEAs). Excluding perioperative events and non-stroke mortality, stroke risks (immediate vs deferred CEA) were 4·1% versus 10·0% at 5 years (gain 5·9%, 95% CI 4·0–7·8) and 10·8% versus 16·9% at 10 years (gain 6·1%, 2·7–9·4); ratio of stroke incidence rates 0·54, 95% CI 0·43–0·68, p

The definition of health literacy is provided along with information substantiating its importance. Focused initiatives, the consequences of poor health literacy, and at-risk populations are briefly discussed. The focus of this article is the application of health literacy principles to the discipline of orofacial myology and how the promotion of health literacy facilitates positive growth for patients, orfacial myologists, and the professions. The article concludes with a vision for a health literate society.

The process of selecting candidate areas for inclusion in a regional conservation network should include not only delineating appropriate land units for selection and defining targets for representing features of interest, but also determining the suitability of land units for conservation purposes. We developed an explicit rating of conservation suitability by applying fuzzy-logic functions in a knowledge base to ecological condition and socio-economic attributes of land units in the interior Columbia River basin, USA. Suitability was converted to unsuitability to comprise a cost criterion in selecting regional conservation networks. When unsuitability was the sole cost criterion or was combined with land area as cost, only about one-third of the area selected was rated suitable, due to inclusion of unsuitable land to achieve representation of conservation targets (vegetation cover-type area). Selecting only from land units rated suitable produced networks that were 100% suitable, reasonably efficient, and most likely to be viable and defensible, as represented in our knowledge-based system. However, several conservation targets were not represented in these networks. The tradeoff between suitability and effectiveness in representing targets suggests that a multi-stage process should be implemented to address both attributes of candidate conservation networks. The suitability of existing conservation areas was greater than that of most alternative candidate networks, but 59% of land units containing conservation areas received a rating of unsuitable, due in part to the presence of units only partially occupied by conservation areas, in which unsuitability derived from conditions in non-conserved areas.