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Shuffling and freezing while walking can impair function in patients with Parkinson disease (PD). Open-loop devices that provide fixed-velocity visual or auditory cues can improve gait but may be unreliable or exacerbate freezing of gait in some patients. We examined the efficacy of a closed-loop, accelerometer-driven, wearable, visual-auditory cueing device in 13 patients with PD with off-state gait impairment at baseline and after 2 weeks of twice daily (30 minute duration) at-home use. We measured gait velocity, stride length, and cadence using a validated electronic gait-analysis system. Subjects underwent standard motor assessment and completed a self-administered Freezing of Gait Questionnaire (FOGQ) (range 0-24; lower is better). After training, device use enhanced walking velocity (61.6 ± 20.1 cm/s to 72.6 ± 26.5 cm/s, p = 0.006) and stride length (74.3 ± 16.4 cm to 84.0 ±18.5 cm, p = 0.004). Upon device removal, walking velocity (64.5 ± 21.4 cm/s to 75.4 ± 21.5 cm/s, p < 0.001) and stride length (79.0 ± 20.3 cm to 88.8 ± 17.7 cm, p = 0.003) exhibited a greater magnitude of change, suggesting immediate residual benefits. Also upon device removal, nearly 70 percent of subjects improved by at least 20 percent in either walking velocity, stride length, or both. An overall improvement in gait was measured by the FOGQ (14.2 ±1.9 to 12.4 ± 2.5, p = 0.02). Although issues related to compliance and response variability render a definitive interpretation of study outcome difficult, devices using closed-loop sensory feedback appear to be effective and desirable nonpharmacologic interventions to improve walking in selected individuals with PD. [ABSTRACT FROM AUTHOR]

Background: Ligation and division of the saphenofemoral junction (L/D SFJ) can protect against the danger of venous thromboembolism (VTE) associated with greater saphenous vein (GSV) radiofrequency ablation (RFA). Although this procedure is regarded as clean from an infection standpoint, surgical site infection (SSI) can offset its thromboembolic benefit. We questioned whether SSI associated with L/D SFJ could be minimized by a single preoperative dose of antibiotic., Methods: A retrospective cohort study was performed on 902 ambulatory surgery patients who underwent 953 consecutive RFAs of the GSV in combination with L/D SFJ. A single dose of preoperative antibiotic was administered 1 hour before incision to some patients (n = 449 extremities), with all other patients receiving no antibiotic (n = 504). Primary outcome measure was SSI categorized based on type of therapy required (1: oral antibiotic, 2: hospitalization for intravenous antibiotic and/or wound debridement), with a secondary outcome measure of VTE., Results: VTE occurred in 10 patients (1%) and included three pulmonary emboli. The majority of VTE were calf deep vein thromboses (n = 7). SSI developed in 78 patients (8.2%) with groin, thigh, and calf distributions of 47%, 8%, and 45%, respectively. All category 2 infections (n = 8, 10%) occurred in control subjects, and the majority were located in the groin. Body mass index significantly increased risk for both overall (odds ratio [OR]: 1.09, 95% confidence interval [CI]: 1.05-1.14, P < 0.0001) and groin (OR: 1.08, 95% CI: 1.02-1.14, P = 0.01) SSI as well as VTE (OR: 1.17, 95% CI: 1.08-1.30, P = 0.003). Diabetes was a significant risk for groin SSI (OR: 5.13, 95% CI: 1.44-18.26, P = 0.01). Antibiotic was associated with a significantly reduced risk for both overall (OR: 0.54, 95% CI: 0.37-0.89, P = 0.02) and groin (OR: 0.34, 95% CI: 0.16-0.73, P = 0.01) SSI. Furthermore, prophylaxis eliminated category 2 infections (P = 0.008) and was associated with a significantly lower risk of VTE (OR: 0.11, 95% CI: 0.01-0.85, P = 0.01). Although SSI was noted more commonly in extremities with thromboembolic complications (20% [n = 2] vs. 8.1% [n = 76] in those without), this trend was not significant and could not account for the antibiotic effect on VTE., Conclusions: L/D SFJ combined with RFA of the GSV, when treated as a clean procedure and not prophylaxed with antibiotic, carries a significant risk of SSI. While diabetes and high body mass index are patient-associated SSI risk factors, a single dose of preoperative antibiotic significantly reduces the rate of all infection, eliminates the danger of serious infection, and is associated with minimal VTE., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background: The American College of Surgeons Committee on Trauma guidelines for trauma center verification stipulate that the responsible surgeon be present within 15 minutes of the arrival of a critically injured patient. Recently, these guidelines were liberalized, extending the response time to 30 minutes in level III trauma centers. This study evaluated the potential impact of this guideline change on the delivery of care at Ohio's level III trauma centers. We hypothesized that there would be no measurable difference in the emergency department (ED) length of stay (LOS), ED disposition, and facility mortality after enactment of this mandate, which extended the surgeon response time from 15 minutes to 30 minutes at level III trauma centers., Methods: Data were collected from the trauma registries of 13 level III trauma centers in Ohio beginning 2 years before and ending 2 years after June 30, 2004, the day the response time was extended to 30 minutes. Statistical analyses were completed comparing the two groups in terms of demographic and clinical characteristics, surgeon response time, ED disposition, ED LOS, and facility mortality., Results: A total of 1,076 patients were treated during the 4-year period. The type of trauma, age, and Injury Severity Score were similar between the two groups. The mean (+/-SD) surgeon response times before and after the rule change were 14.8 minutes (+/-19.4 minutes) and 15.5 minutes (+/-22.3 minutes), respectively. The two groups also had similar ED LOS (mean = 2.9, median = 2.5 for both groups), rates of transfer to higher level centers (34.4% vs. 32.8%; p = 0.58), and facility mortality rates (10.0% vs. 11.2%; p = 0.55)., Conclusion: The extension of the surgeon response time from 15 minutes to 30 minutes did not adversely affect the outcomes of trauma patients at Ohio's level III trauma centers. Furthermore, the surgeon response time was similar before and after the rule change.

The objectives of this study were to 1) describe the characteristics of the backpacks used by students 10-18 years of age, 2) describe self reported pain related to backpack use and 3) evaluate the relationship between self reported pain and perceived backpack weight, duration of backpack use and posture when wearing a backpack. A cross-sectional survey of 871 students assessed the features of the backpack carried; the self perceived backpack weight, duration and posture; and any backpack related pain. Results indicate that 99% of students surveyed carry backpacks, 83% carry their backpacks over both shoulders and the presence of adjustable shoulder straps were the most common feature of the backpacks. Half of the students perceive their backpack as heavy and 46% indicate they carry the backpack 10-20 minutes to and from school. Pain attributed to backpack use was reported by 33.5% of the students. Perceived backpack weight, duration of backpack carriage, posture, gender and school district were significantly associated with reported symptoms. Although other socioeconomic and demographic characteristics may contribute to backpack related pain, this study suggests that students perceive a relationship between backpack use, the duration of use, posture and pain supporting the suggestion that simple weight-based controls of backpacks may not be sufficient to eliminate pain perceived as due to backpack use.

The objective of our study was to investigate the association between daily pediatric asthma hospital visits and daily concentrations of aeroallergens and their specific species. Records of daily asthma visits in Cincinnati area were retrieved from Cincinnati Children's Hospital Medical Center and aeroallergen sampling was performed by the Button Inhalable Sampler. The Poisson generalized linear model was carried out in which the log of the number of asthma hospital visits was related to aeroallergen level, treated as a continuous variable with adjustment for seasonal time trend, day of the week, ozone and PM(2.5) concentrations, temperature and humidity. The aeroallergens having a significant impact on asthma hospital visits were ragweed, oak/maple and Pinaceae pollen. Their relative risks on asthma hospital visits with respect to a 100 counts/m(3) increase in concentration were in the range of 1.23 to 1.54. The effects in causing the asthma exacerbation were delayed by 3 or 5 days.

Background and Purpose: Many advances were made in stroke prevention strategies during the 1990s, and yet temporal trends in stroke incidence and case-fatality have not been reported in the United States. Blacks have a 2-fold higher risk of stroke; however, there are no data over time showing if any progress has been made in reducing racial disparity in stroke incidence. The objective of this study was to examine temporal trends in stroke incidence and case-fatality within a large, biracial population during the 1990s., Methods: Within a biracial population of 1.3 million, all strokes were ascertained at all local hospitals using International Classification of Diseases, 9th Revision codes during July 1993 to June 1994 and again in 1999. A sampling scheme was used to ascertain cases in the out-of-hospital setting. Race-specific incidence and case-fatality rates were calculated and standardized to the 2000 US Census population. A population-based telephone survey regarding stroke risk factor prevalence and medication use was performed in 1995 and 2000., Results: There were 1954 first-ever strokes in 1993-1994 and 2063 first-ever strokes in 1999. The annual incidence of first-ever hospitalized stroke did not significantly change between study periods: 158 per 100,000 in both 1993-1994 and 1999 (P=0.97). Blacks continue to have higher stroke incidence than whites, especially in the young; however, case-fatality rates continue to be similar between races and are not changing over time. Medication use for treatment of stroke risk factors significantly increased in the general population between study periods., Conclusions: Despite advances in stroke prevention treatments during the 1990s, the incidence of hospitalized stroke did not decrease within our population. Case-fatality also did not change between study periods. Excess stroke mortality rates seen in blacks nationally are likely the result of excess stroke incidence and not case-fatality, and the racial disparity in stroke incidence did not change over time.

A time series model was fitted to the pollen concentration data collected in the Greater Cincinnati area for the Cincinnati Childhood Allergy and Air Pollution Study (CCAAPS). A traditional time series analysis and temporal variogram approach were applied to the regularly spaced databases (collected in 2003) and irregularly spaced ones (collected in 2002), respectively. The aim was to evaluate the effect of the sampling frequency on the sampling precision in terms of inverse of standard error of the overall level of mean value across time. The presence of high autocorrelation in the data was confirmed and indicated some degree of temporal redundancy in the pollen concentration data. Therefore, it was suggested that sampling frequency could be reduced from once a day to once every several days without a major loss of sampling precision of the overall mean over time. Considering the trade-offs between sampling frequency and the possibility of sampling bias increasing with larger sampling interval, we recommend that the sampling interval should take values from 3 to 5 days for the pollen monitoring program, if the goal is to track the long-term average.

Objective: Diabetes is a well known risk factor for stroke, but the impact of diabetes on stroke incidence rates is not known. This study uses a population-based study to describe the epidemiology of ischemic stroke in diabetic patients., Research Design and Methods: Hospitalized cases were ascertained by ICD-9 discharge codes, prospective screening of emergency department admission logs, and review of coroner's cases. A sampling scheme was used to ascertain cases in the out-of-hospital setting. All potential cases underwent detailed chart abstraction by study nurses followed by physician review. Diabetes-specific incidence rates, case fatality rates, and population-attributable risks were estimated., Results: Ischemic stroke patients with diabetes are younger, more likely to be African American, and more likely to have hypertension, myocardial infarction, and high cholesterol than nondiabetic patients. Age-specific incidence rates and rate ratios show that diabetes increases ischemic stroke incidence at all ages, but this risk is most prominent before age 55 in African Americans and before age 65 in whites. One-year case fatality rates after ischemic stroke are not different between those patients with and without diabetes., Conclusions: Given the "epidemic" of diabetes, with substantially increasing diabetes prevalence each year across all age- and race/ethnicity groups, the significance of diabetes as a risk factor for stroke is becoming more evident. Diabetes is clearly one of the most important risk factors for ischemic stroke, especially in those patients less than 65 years of age. We estimate that 37-42% of all ischemic strokes in both African Americans and whites are attributable to the effects of diabetes alone or in combination with hypertension.

The objective of this study was to evaluate the PM(2.5) monitoring network established in the Greater Cincinnati and Northern Kentucky metropolitan area for measuring the 24 h integrated PM(2.5) concentration, as well as-at selected sites-hourly PM(2.5) concentration and 24 h integrated PM(2.5) speciation. The data collected during three years at 13 measurement sites were analyzed for spatial and temporal variations. It was found that both daily and hourly concentrations of PM(2.5) have low spatial variation due to a regional influence of secondary ammonium sulfate. In contrast, the trace element concentrations had high spatial variation. Seasonal variation accounted for most of the total temporal variation (60%), while yearly, monthly, weekly and daily variations were lower. The variance components and cluster analyses were applied to optimize the number of sites for measuring the 24 h PM(2.5) concentration. It was found that the 13-site network may be optimized by reducing the number of sites to 8, which would result in a relative precision reduction of 9% and a relative cost reduction of 36%. At the same time, the data suggest that the spatial resolution of speciation monitors and real-time PM(2.5) mass monitors should be increased to better represent spatial and temporal variations of the markers of local air pollution sources.

Background and Purpose: Excess mortality resulting from stroke is an important reason why blacks have higher age-adjusted mortality rates than whites. This observation has 2 possible explanations: Strokes occur more commonly among blacks or blacks have higher mortality rates after stroke. Our population-based epidemiological study is set in the Greater Cincinnati/Northern Kentucky region of 1.31 million people, which is representative of the US white and black populations with regard to many demographic and socioeconomic characteristics., Methods: Hospitalized cases were ascertained by International Classification of Diseases (ninth revision) discharge codes, prospective screening of emergency department admission logs, and review of coroner's cases. A sampling scheme was used to ascertain cases in the out-of-hospital setting. All potential cases underwent detailed chart abstraction by study nurses, followed by physician review. Race-specific incidence and case fatality rates were calculated., Results: We identified 3136 strokes during the study period (January 1, 1993, to June 30, 1994). Stroke incidence rates were higher for blacks at every age, with the greatest risk (2- to 5-fold) seen in young and middle-aged blacks (<65 years of age). Case fatality rates did not differ significantly in blacks compared with whites. Applying the resulting age- and race-specific rates to the US population in 2002, we estimate that 705,000 to 740,000 strokes have occurred in the United States, with a minimum of 616,000 cerebral infarctions, 67,000 intracerebral hemorrhages, and 22,000 subarachnoid hemorrhages., Conclusions: Excess stroke-related mortality in blacks is due to higher stroke incidence rates, particularly in the young and middle-aged. This excess burden of stroke incidence among blacks represents one of the most serious public health problems facing the United States.

Background and Purpose: Intracerebral hemorrhage (ICH) has a 30-day mortality rate of 40% to 50% and lacks a proven treatment. We report a preplanned, midpoint analysis of the first population-based, case-control study that examines both genetic and environmental risk factors of ICH., Methods: We prospectively identified cases of hemorrhagic stroke at all 16 hospitals in the Greater Cincinnati/Northern Kentucky region. All cases underwent medical record and neuroimaging review. Cases enrolled in the direct interview and genetic sampling arm of the study were matched to population-based control subjects by age, race, and sex. Multivariable logistic regression was performed to identify significant independent risk factors., Results: We enrolled 188 cases of ICH (67 lobar, 121 nonlobar) and 366 control subjects in the direct interview arm of the study. Significant independent risk factors for lobar ICH included the presence of an apolipoprotein E2 or E4 allele, frequent alcohol use, prior stroke, and first-degree relative with ICH. Significant independent risk factors for nonlobar ICH were hypertension, prior stroke, and first-degree relative with ICH. An increasing level of education was associated with a decreased risk of nonlobar ICH. The attributable risk of apolipoprotein E2 or E4 for lobar ICH was 29%, and the attributable risk of hypertension for nonlobar ICH was 54%., Conclusions: There is significant epidemiological evidence that the pathophysiology of ICH varies by location. We estimate that a third of all cases of lobar ICH are attributable to possession of an apolipoprotein E4 or E2 allele and that half of all cases of nonlobar ICH are attributable to hypertension.

Background and Purpose: Subarachnoid hemorrhage (SAH) caused by ruptured intracranial aneurysm affects approximately 16 000 Americans annually, and almost 40% of affected patients die within 30 days despite the best current therapy. Prevention of SAH is therefore of paramount importance. We present a preliminary analysis of risk factors for SAH from our population-based, case-control study., Methods: Cases were prospectively collected and matched 2:1 by age, race, and gender to controls using random digit dialing. Personal risk factor history, family history, neuroimaging data, and genetic samples were obtained. Univariate and bivariate analyses were performed and population-attributable risks estimated. Multivariable analysis was performed using conditional logistic regression., Results: Between June 1997 and February 2000, 107 cases and 197 controls were enrolled. In bivariate analyses, a large proportion of population-attributable risk for SAH could be explained by modifiable risk factors: smoking, hypertension, and heavy alcohol use. In multivariable analysis, current cigarette smoking, history of hypertension, frequent alcohol use, lower body mass index, and a family history of a relative with SAH or intracranial aneurysm were found to be significant, independent risk factors for SAH., Conclusion: Our data confirm previous reports that SAH clusters within some families independent of environmental risk factors, suggesting that SAH has a significant genetic component. Yet, even among families at increased risk of SAH, smoking cessation, treatment of hypertension, and reduced alcohol intake may substantially decrease SAH risk. The independent associations with heavy alcohol use and low body mass index with SAH may be confounded by smoking and require further study.