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The author discusses the history of Soviet espionage in the U.S. from 1924 to 1933. Topics explored include the establishment of the Amtorg Trading Corporation in New York in 1924 which served as the center of Soviet intelligence operations, the diplomatic recognition of the Soviet Union in the U.S. in 1933 following the election of then U.S. President Franklin D. Roosevelt, and the U.S. government investigation of communist activities led by then Representative Hamilton Fish of New York.

Introduction: Pulse Oximetry (PO) is widely used for the noninvasive detection of hypoxemia, particularly in the perioperative setting. Research regarding the perioperative assessment of nursing knowledge of PO continues to evolve. Prior evaluations have identified relative knowledge deficits among nurses regarding physiologic principles, data interpretation, and clinical application. Such deficits need identification and targeted education to prevent perioperative patient mismanagement. Aim: To assess nursing knowledge of PO in perioperative and critical care settings of a single center in the United States and to analyse identified knowledge deficits. Materials and Methods: A validated cross-sectional questionnaire, surveying PO principle consisting of 21 true/ false and 3 open-ended questions, was administered to 150 participants in the Post Anaesthesia Care Unit (PACU) and Medical Respiratory ICU (MRICU). Univariate analysis of nursing Total Knowledge Score (TKS), years of clinical experience, and current practice settings was performed. Significance was set at p<0.05. Before collecting data, this educational study was deemed not human subjects research by the Virginia Commonwealth University Institutional Review Board (VCU IRB). Results: A total of 51 questionnaires were completed, with a 34% response rate. The mean TKS for the true/false questionnaire was 16.4±2.0. There was no significant difference in TKS between PACU and MRICU nurses (16.5±1.7 vs. 16.2±2.5, respectively, p=0.27). Ninety-eight percent of all nurses scored >50% correct while 13.7% scored >90% (p=0.19 and p=0.74, respectively). The lowest percentages of correct responses (<50%) were seen in questions 3 and 16, which pertained to physiologic principles of PO. There was no significant difference in scoring percentiles between MRICU and PACU nurses, nor was there significant difference in TKS based on clinical experience. Conclusion: The mean TKS of nurses in the study was higher than the mean TKS of nurses in reference studies. There was no significant difference in TKS between PACU and MRICU nurses. Furthermore, clinical experience did not correlate with TKS scores. The authors believe analysing these knowledge deficits may offer educational opportunities in initial and continuing nursing education as well as routine postgraduate assessments. [ABSTRACT FROM AUTHOR]

Objective: In occupational hearing conservation programmes, age adjustments may be used to subtract expected age effects. Adjustments used in the U.S. came from a small dataset and overlooked important demographic factors, ages, and stimulus frequencies. The present study derived a set of population-based age adjustment tables and validated them using a database of exposed workers. Design: Cross-sectional population-based study and retrospective longitudinal cohort study for validation. Study sample: Data from the U.S. National Health and Nutrition Examination Survey (unweighted n = 9937) were used to produce these tables. Male firefighters and emergency medical service workers (76,195 audiograms) were used for validation. Results: Cross-sectional trends implied less change with age than assumed in current U.S. regulations. Different trends were observed among people identifying with non-Hispanic Black race/ethnicity. Four age adjustment tables (age range: 18–85) were developed (women or men; non-Hispanic Black or other race/ethnicity). Validation outcomes showed that the population-based tables matched median longitudinal changes in hearing sensitivity well. Conclusions: These population-based tables provide a suitable replacement for those implemented in current U.S. regulations. These tables address a broader range of worker ages, account for differences in hearing sensitivity across race/ethnicity categories, and have been validated for men using longitudinal data. [ABSTRACT FROM AUTHOR]

The rapidly expanding martial arts industry, which is presently unregulated within the United States, has seen multiple coaches convicted of sex offenses in recent years. However, there is currently no existing literature on sexual assault within the martial arts industry. We used major search platforms to collect media reports concerning martial arts coaches who were convicted of sex offenses within the United States. We analyzed the reports for information concerning the perpetrators, victims, and offenses as a first step toward filling the need for insight in this area. We found that a significant number of convicted sex offenders resumed martial arts coaching following initial law enforcement intervention. [ABSTRACT FROM AUTHOR]

The 21 genera and 98 species of Sciomyzidae known from eastern Canada and the adjacent northeastern United States are keyed and illustrated. The eastern Canadian species are reviewed, with distributional maps and brief biological summaries provided for each species. [ABSTRACT FROM AUTHOR]

Objective: Assessment of the auditory risk associated with sound from ballistic N-waves produced by a rifle bullet. Design: Acoustical recordings of ballistic N-waves passing through a microphone array at 6.4 metres down range were analysed to determine (a) the trajectory of the bullet, (b) the distance between the trajectory and each microphone (less than 1.3 m), and (c) the numbers of permissible exposures according to both damage-risk criteria for impulsive noise in the current U.S. military standard (MIL-STD-1474E). Study Sample: The gun was an AR-15 style semiautomatic rifle configured to fire a 0.50 calibre Beowulf00AE cartridge. Four sample shots were recorded for each of four microphone spacing conditions and five kinds of ammunition (80 shots in total). Results: The ballistic N-waves recorded in this study would constitute a significant auditory risk to unprotected listeners at all distances sampled. The numbers of permissible exposures decreased as the distance to the bullet trajectory decreased, decreased with increased bullet length, and departed from linear increases as the bullet velocity increased. Conclusions: Unprotected exposure to a ballistic N-wave from a supersonic 0.50 calibre bullet presents a significant risk to hearing at distances of 6.4 metres down range and through trajectories within 1.2 metres of an ear. [ABSTRACT FROM AUTHOR]

Background: The advent of value-based care, in which surgeons and hospitals accept more responsibility for clinical and financial results, has increased the focus on surgeon- and hospital-specific outcomes. However, methods to identify high-quality, low-cost surgeons are not well developed.Questions/purposes: (1) Is there an association between surgeon THA volume and 90-day Centers for Medicare & Medicaid Services (CMS) Part A payments, readmissions, or mortality? (2) What proportion of THAs in the United States is performed by low- and high-volume surgeons?Methods: We performed a retrospective analysis of the CMS Limited Data Set on all primary elective THAs performed in the United States (except Maryland) between January 2013 and June 2016 on patients insured by Medicare. This represented 409,844 THAs totaling more than USD 7.7 billion in direct CMS expenditures. Surgeons were divided into five groups based on annualized volume of CMS elective THAs over the study period. Using linear and logistic regression, we calculated and compared 90-day CMS Part A payments, readmissions, and mortality among the groups. For each episode, demographic information (age, sex, and race), geographic location, and Elixhauser comorbidities were calculated to control for major confounding factors in the regression.Results: When compared with the highest volume group, each lower volume group had increased payments, increased readmission rates, and increased mortality rates in a stepwise fashion when controlling for patient-specific variables including Elixhauser comorbidity index, demographic information, region, and background trend. The lowest volume group resulted in 27.2% more CMS payments per case (p < 0.001; 95% confidence interval [CI], 26.6%-27.8%), had an increased readmission odds ratio (OR) of 1.8 (p < 0.001; 95% CI, 1.7-1.9), and an increased mortality OR of 4.7 (p < 0.001; 95% CI, 4.0-5.5) when compared with the highest volume group. There was also variation within volume groups: some lower volume surgeons had lower payments, readmissions, and mortality than some higher volume surgeons despite the general trend. In terms of CMS volume, surgeons who were at least moderate volume (11+ annual cases) performed 78% of THAs and represented 26% of operating surgeons. The low- and lowest volume surgeons (10 or fewer annual cases) performed only 22% of THAs in the United States while representing 74% of unique operating surgeons.Conclusions: There is a strong association between a surgeon's Medicare volume and lower CMS payments, readmissions, and mortality. Furthermore, the majority of Medicare THAs in the United States are performed by surgeons who perform > 10 CMS operations annually. Compared with previous work, these results suggest a trend toward higher volume surgeons in the Medicare population. The results also suggest a benefit to the shift toward higher volume surgeons in reducing payments, readmissions, and mortality for elective THA in the United States. However, given that payments, readmission, and mortality of surgeons varied widely, it is important to note that available individual CMS data can be used to directly evaluate each individual surgeon based on their actual results well as through association with volume.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: The Centers for Medicare & Medicaid Services (CMS) launched the Bundled Payment for Care Improvement (BPCI) initiative in 2013 to create incentives to improve outcomes and reduce costs in various clinical settings, including total hip arthroplasty (THA). This study seeks to quantify BPCI initiative outcomes for THA and to determine the optimal party (for example, hospital versus physician group practice [PGP]) to manage the program.Questions/purposes: (1) Is BPCI associated with lower 90-day payments, readmissions, or mortality for elective THA? (2) Is there a difference in 90-day payments, readmissions, or mortality between episodes initiated by PGPs and episodes initiated by hospitals for elective THA? (3) Is BPCI associated with reduced total Elixhauser comorbidity index or age for elective THA?Methods: We performed a retrospective analysis on the CMS Limited Data Set on all Medicare primary elective THAs without a major comorbidity performed in the United States (except Maryland) between January 2013 and March 2016, totaling more than USD 7.1 billion in expenditures. Episodes were grouped into hospital-run BPCI (n = 42,922), PGP-run BPCI (n = 44,662), and THA performed outside of BPCI (n = 284,002). All Medicare Part A payments were calculated over a 90-day period after surgery and adjusted for inflation and regional variation. For each episode, age, sex, race, geographic location, background trend, and Elixhauser comorbidities were determined to control for major confounding variables. Total payments, readmissions, and mortality were compared among the groups with logistic regression.Results: When controlling for demographics, background trend, geographic variation, and total Elixhauser comorbidities in elective Diagnosis-Related Group 470 THA episodes, BPCI was associated with a 4.44% (95% confidence interval [CI], -4.58% to -4.30%; p < 0.001) payment decrease for all participants (USD 1244 decrease from a baseline of USD 18,802); additionally, odds ratios (ORs) for 90-day mortality and readmissions were unchanged. PGP groups showed a 4.81% decrease in payments (95% CI, -5.01% to -4.61%; p < 0.001) after enrolling in BPCI (USD 1335 decrease from a baseline of USD 17,841). Hospital groups showed a 4.04% decrease in payments (95% CI, -4.24% to 3.84%; p < 0.01) after enrolling in BPCI (USD 1138 decrease from a baseline of USD 19,799). The decrease in payments of PGP-run episodes was greater compared with hospital-run episodes. ORs for 90-day mortality and readmission remained unchanged after BPCI for PGP- and hospital-run BPCI programs. Patient age and mean Elixhauser comorbidity index did not change after BPCI for PGP-run, hospital-run, or overall BPCI episodes.Conclusions: Even when controlling for decreasing costs in traditional fee-for-service care, BPCI is associated with payment reduction with no change in adverse events, and this is not because of the selection of younger patients or those with fewer comorbidities. Furthermore, physician group practices were associated with greater payment reduction than hospital programs with no difference in readmission or mortality from baseline for either. Physicians may be a more logical group than hospitals to manage payment reduction in future healthcare reform.Level Of Evidence: Level II, economic and decision analysis. [ABSTRACT FROM AUTHOR]

Globally, one in three adults has some level of measurable hearing loss, and 1.1 billion young persons are at risk for hearing loss attributable to noise exposure. Although noisy occupations such as construction, mining, and manufacturing are primary causes of hearing loss in adults, nonoccupational noise also can damage hearing. Loud noises can cause permanent hearing loss through metabolic exhaustion or mechanical destruction of the sensory cells within the cochlea. Some of the sounds of daily life, including those made by lawn mowers, recreational vehicles, power tools, and music, might play a role in the decline in hearing health. Hearing loss as a disability largely depends on a person's communication needs and how hearing loss affects the ability to function in a job. The loss of critical middle and high frequencies can significantly impair communication in hearing-critical jobs (e.g., law enforcement and air traffic control). [ABSTRACT FROM AUTHOR]

The National Institute for Occupational Safety and Health (NIOSH) sponsored tests of three earplug fit-test systems (NIOSH HPD Well-Fit, Michael & Associates FitCheck, and Honeywell Safety Products VeriPRO). Each system was compared to laboratory-based real-ear attenuation at threshold (REAT) measurements in a sound field according to ANSI/ASA S12.6-2008 at the NIOSH, Honeywell Safety Products, and Michael & Associates testing laboratories. An identical study was conducted independently at the U.S. Army Aeromedical Research Laboratory (USAARL), which provided their data for inclusion in this article. The Howard Leight Airsoft premolded earplug was tested with twenty subjects at each of the four participating laboratories. The occluded fit of the earplug was maintained during testing with a soundfield-based laboratory REAT system as well as all three headphone-based fit-test systems. The Michael & Associates lab had the highest average A-weighted attenuations and smallest standard deviations. The NIOSH lab had the lowest average attenuations and the largest standard deviations. Differences in octave-band attenuations between each fit-test system and the American National Standards Institute (ANSI) sound field method were calculated (Attenfit-test- AttenANSI). A-weighted attenuations measured with FitCheck and HPD Well-Fit systems demonstrated approximately ±2 dB agreement with the ANSI sound field method, but A-weighted attenuations measured with the VeriPRO system underestimated the ANSI laboratory attenuations. For each of the fit-test systems, the average A-weighted attenuation across the four laboratories was not significantly greater than the average of the ANSI sound field method. Standard deviations for residual attenuation differences were about ±2 dB for FitCheck and HPD Well-Fit compared to ±4 dB for VeriPRO. Individual labs exhibited a range of agreement from less than a dB to as much as 9.4 dB difference with ANSI and REAT estimates. Factors such as the experience of study participants and test administrators, and the fit-test psychometric tasks are suggested as possible contributors to the observed results. [ABSTRACT FROM AUTHOR]

A major challenge in global sales research is helping managers understand sales ethics across countries. Addressing this challenge, our research investigates whether a few demographic variables and psychographic variables reduce unethical sales behaviors (USBs) in Canada, Mexico, and the USA. Further, using literatures associated with business ethics, national culture, and customer orientation advocacy, we hypothesize why sales managers should expect similarities and differences in USBs between countries. We tested hypotheses using a sales contest scenario and six USBs, examining survey responses from 948 business-to-business salespeople of a multinational company's sales force in Canada, Mexico, and the USA. The results reveal that several psychographic variables (such as commitment, relationship to sales manager, and achievement need) affect salespeople's tendency to engage in USBs differently in each country. In addition, business ethics, individualism, and customer orientation advocacy associated with each country can be used to anticipate similarities and differences in USBs between countries. This research offers important theoretical contributions and implications for more effectively managing sales forces and reducing USBs across countries. [ABSTRACT FROM AUTHOR]

Through a critical rhetorical analysis of US elite and popular press coverage of global warming, this essay explores the structuring presence and implications of apocalyptic framing. We found that the hallmarks of apocalyptic rhetoric-a linear temporality emphasizing a catastrophic end-point that is more or less outside the purview of human agency-permeate selected discourse. Two variants of the apocalyptic frame impact human agency: tragic apocalypse constitutes global warming as a matter of cosmic Fate; and comic apocalypse suggests that mistaken humans have a capacity to influence (within limits) the global warming narrative's end. We conclude with suggestions for structuring climate change communication in ways that enable more members of the public to become active advocates for, and participants in, mitigating global warming. [ABSTRACT FROM AUTHOR]

The National Institute for Occupational Safety and Health and the Environmental Protection Agency sponsored the completion of an interlaboratory study to compare two fitting protocols specified by ANSI S12.6-1997 (R2002) [(2002). American National Standard Methods for the Measuring Real-Ear Attenuation of Hearing Protectors, American National Standards Institute, New York]. Six hearing protection devices (two earmuffs, foam, premolded, custom-molded earplugs, and canal-caps) were tested in six laboratories using the experimenter-supervised, Method A, and (naïve) subject-fit, Method B, protocols with 24 subjects per laboratory. Within-subject, between-subject, and between-laboratory standard deviations were determined for individual frequencies and A-weighted attenuations. The differences for the within-subject standard deviations were not statistically significant between Methods A and B. Using between-subject standard deviations from Method A, 3–12 subjects would be required to identify 6-dB differences between attenuation distributions. Whereas using between-subject standard deviations from Method B, 5–19 subjects would be required to identify 6-dB differences in attenuation distributions of a product tested within the same laboratory. However, the between-laboratory standard deviations for Method B were -0.1 to 3.0 dB less than the Method A results. These differences resulted in considerably more subjects being required to identify statistically significant differences between laboratories for Method A (12–132 subjects) than for Method B (9–28 subjects). [ABSTRACT FROM AUTHOR]

A Collaborative Report from the American Associations for Vascular Surgery/Society for Vascular Surgery,* Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Peripheral Arterial Disease)—Summary of Recommendations [Copyright &y& Elsevier]

The article discusses the important role of air conditioning (AC) systems in green buildings in the U.S. Topics include the impact of air conditioning on the growth of the Sunbelt region in the U.S., the energy consumption of the majority of air conditioning systems for residential and commercial use, the energy distribution efficiency of AC, and the importance of AC humidity control.

To assist a technical review of a potential application for a geologic repository, a reactive transport model is presented for the ambient hydrogeochemical system at Yucca Mountain (YM). The model simulates two-phase, non-isothermal, advective and diffusive flow and transport through one-dimensional matrix and fracture continua (dual permeability) containing ten kinetically reactive hydrostratigraphic layers. We developed a thermodynamic interpretation of ambient groundwater chemistry at YM from limited analytical data and then combined it with insights from experimental and site-specific data to craft a conceptual model describing thermodynamic and kinetic relationships in the mineral/glass–water–gas system. The model was calibrated by adjusting uncertain thermodynamic and kinetic parameters to reflect observed trends at YM. The following calibration criteria were used to ensure that model predictions are consistent with hydrochemical and petrologic data from YM: (1) calculated multicomponent matrix pore water compositions do not vary significantly from reinterpreted analytical data; (2) simulated variations in matrix silica concentrations with depth are bounded by the observed analytical range; and (3) feldspars and glass dissolve while clays and calcite precipitate. The largest changes in calculated species concentrations occur in response to glass dissolution. Simulated matrix groundwater compositions at the depth of the potential repository are largely inherited from percolating waters rather than controlled by in situ chemical reactions. Predictions about groundwater flow pathways in the ambient YM system are sensitive to assumptions regarding percolation flux and fracture–matrix interactions. Confidence in complex reactive transport models of the thermally perturbed YM repository system depends on successful representation of ambient system conditions. [Copyright &y& Elsevier]

Provisions of the National Historical Preservation Act of 1966, particularly Section 106 of that Act, require the Yuma Proving Ground (YPG) to conduct archaeological surveys and assess cultural resources to evaluate potential effects of planned military testing activities on those cultural resources considered eligible or potentially eligible for inclusion in the National Register of Historic Places. Landscape reconstruction was performed using aerial photography and satellite image interpretations, ground verification including detailed soils geomorphology descriptions, and archaeological surveys. Geographic Information System overlay analyses were used to determine the preferential distribution of cultural resources in the study area. A vast majority of the 40 mapped cultural sites are located on Pleistocene age geomorphic surfaces. Few sites occurred on Holocene age surfaces. Spatial relationships between geomorphology and archaeology were supported by chi-square statistical tests, rejecting the hypothesis that culture is evenly distributed across the landscape as a function of the size of geomorphic surfaces comprising it. Ninety-two percent of cultural resources designated eligible for the National Register of Historic Places occur on Pleistocene age geomorphic surfaces. Results of this interdisciplinary study suggest that both differential preservation of geomorphic surfaces and human behavior act together to explain the spatial distribution of cultural resources at YPG. [ABSTRACT FROM AUTHOR]

Discusses the application of vicarious disqualifications to government lawyers in the U.S. Distinction between public and private law practice; Protection of a client's confidences and secrets; Unavailability of a waiver provision to former federal government lawyers; Provisions of the proposed Model Rules of Professional Conduct.

The National Health and Nutrition Examination Survey (NHANES) is a nationally representative, population-based survey designed to assess the health and nutritional status of the civilian, non-institutionalized US population. Data were collected through a personal interview regarding health history and through physical examination. Earlier NHANES surveys were conducted on a periodic basis; however, in 1999, NHANES began collecting data on a continuing, annual basis. During NHANES I, which ran from 1971–1975, audiometric testing was conducted on adults aged 25–74 years. No subsequent testing of adults was conducted in the NHANES program until 1999, when NHANES began audiometric testing of adults aged 20–69 years. This report examines the hearing levels for adults in the United States and compares them with the hearing data from NHANES I. Hearing levels are grouped by age and are grouped by ethnicity and gender. [ABSTRACT FROM AUTHOR]

The article comments on a study on the effectiveness of the U.S. Army policy on hearing conservation programs (HCPs) published within the issue. It stresses its disagreement with the methodology and conclusions presented by the authors. It expresses views on the design of the study which was aimed at determining whether a group of 675 workers at the Anniston Army Depot in Alabama had incurred occupational noise-induced hearing loss between 1987 and 2001. It also offers additional comments regarding the 3-decibel (dB) exchange rate.

Treated herein are the 113 described species and two described subspecies in 25 genera of the family Sciomyzidae (snail-killing or marsh flies) known from the Americas south of the United States. Included are details on type specimens, references to generic transfers and synonymies, taxonomy, biology, gastropod hosts/prey, immature stages, chromosomes, biological and phenological groups, general distribution, and molecular data. Annotated keys are presented to adults of genera known from the Nearctic-Neotropical interface area and the Neotropics as well as the first key to all sciomyzid genera known from the Nearctic Region. Also presented is the first key to third-instar sciomyzid larvae in the Neotropical Region. Sepedonea isthmi (Steyskal) is placed as a junior synonym of S. annulata Macquart (new status), and Tetanocera plumifera Wulp is placed as a junior synonym of T. plumosa Loew (new status).

Admixture and introgression play a critical role in adaptation and genetic rescue that has only recently gained a deeper appreciation. Here, we explored the geographical and genomic landscape of cryptic ancestry of the endangered red wolf that persists within the genome of a ubiquitous sister taxon, the coyote, all while the red wolf has been extinct in the wild since the early 1980s. We assessed admixture across 120,621 single nucleotiode polymorphism (SNP) loci genotyped in 293 canid genomes. We found support for increased red wolf ancestry along a west-to-east gradient across the southern United States associated with historical admixture in the past 100 years. Southwestern Louisiana and southeastern Texas, the geographical zone where the last red wolves were known prior to extinction in the wild, contained the highest and oldest levels of red wolf ancestry. Further, given the paucity of inferences based on chromosome types, we compared patterns of ancestry on the X chromosome and autosomes. We additionally aimed to explore the relationship between admixture timing and recombination rate variation to investigate gene flow events. We found that X-linked regions of low recombination rates were depleted of introgression, relative to the autosomes, consistent with the large X effect and enrichment with loci involved in maintaining reproductive isolation. Recombination rate was positively correlated with red wolf ancestry across coyote genomes, consistent with theoretical predictions. The geographical and genomic extent of cryptic red wolf ancestry can provide novel genomic resources for recovery plans targeting the conservation of the endangered red wolf., (© 2021 John Wiley & Sons Ltd.)

National and international regulatory and consensus standards setting bodies have previously proposed derating hearing protector ratings to provide a better match between ratings determined in a laboratory and the real-world measurements of attenuation for workers. The National Institute for Occupational Safety and Health has proposed a derating scheme that depends upon the type of protector. This paper examines four real-world studies where personal attenuation ratings (PARs) were measured at least twice, before and after an intervention in earplug fitting techniques. Results from these studies indicate that individualized earplug fitting training dramatically improves a worker's achieved PAR value. Additionally, derating schemes fail to accurately predict the majority of achieved PARs. Because hearing protector fit testing systems are now readily available for use in the workplace, personal attenuation ratings provide a better estimate of worker noise exposures and are able to identify those persons who need additional instruction in fitting hearing protection devices.

Competing Interests: Conflicts of interest None disclosed.

Background: A variety of dermatoses have been reported in the growing number of patients treated with immune-checkpoint inhibitors (ICIs), but the current understanding of cutaneous immune-related adverse events (irAEs) is limited., Objective: To determine the cumulative incidence, distribution, and risk factors of cutaneous irAEs after ICI initiation., Methods: This was a retrospective cohort study of patients in a national insurance claims database including cancer patients treated with ICIs and matched controls., Results: The study included 8637 ICI patients and 8637 matched controls. The overall incidence of cutaneous irAEs was 25.1%, with a median onset time of 113 days. The ICI group had a significantly higher incidence of pruritus, mucositis, erythroderma, maculopapular eruption, vitiligo, lichen planus, bullous pemphigoid, Grover disease, rash, other nonspecific eruptions, and drug eruption or other nonspecific drug reaction. Patients with melanoma and renal cell carcinoma and those receiving combination therapy were at a higher risk of cutaneous irAEs., Limitations: Retrospective design without access to patient chart data., Conclusions: This study identifies cutaneous irAEs in a real-world clinical setting and highlights patient groups that are particularly at risk. The results can aid dermatologists at the bedside in the diagnosis of cutaneous irAEs and in formulating management recommendations to referring oncologists regarding the continuation of ICI therapy., Competing Interests: Conflicts of interest None disclosed., (Copyright © 2021 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Immune-related adverse events (irAEs) are a serious side effect of immune checkpoint inhibitor (ICI) therapy for patients with advanced cancer. Currently, predisposing risk factors are undefined but understanding which patients are at increased risk for irAEs severe enough to require hospitalization would be beneficial to tailor treatment selection and monitoring., Methods: We performed a retrospective review of patients with cancer treated with ICIs using unidentifiable claims data from an Aetna nationwide US health insurance database from January 3, 2011 to December 31, 2019, including patients with an identified primary cancer and at least one administration of an ICI. Regression analyses were performed. Main outcomes were incidence of and factors associated with irAE requiring hospitalization in ICI therapy., Results: There were 68.8 million patients identified in the national database, and 14 378 patients with cancer identified with at least 1 administration of ICI in the study period. Patients were followed over 19 117 patient years and 504 (3.5%) developed an irAE requiring hospitalization. The incidence of irAEs requiring hospitalization per patient ICI treatment year was 2.6%, rising from 0% (0/71) in 2011 to 3.7% (93/2486) in 2016. Combination immunotherapy (OR: 2.44, p<0.001) was associated with increased odds of developing irAEs requiring hospitalization, whereas older patients (OR 0.98 per additional year, p<0.001) and those with non-lung cancer were associated with decreased odds of irAEs requiring hospitalization (melanoma OR: 0.70, p=0.01, renal cell carcinoma OR: 0.71, p=0.03, other cancers OR: 0.50, p<0.001). Sex, region, zip-code-imputed income, and zip-code unemployment were not associated with incidence of irAE requiring hospitalization. Prednisone (72%) and methylprednisolone (25%) were the most common immunosuppressive treatments identified in irAE hospitalizations., Conclusions: We found that 3.5% of patients initiating ICI therapy experienced irAEs requiring hospitalization and immunosuppression. The odds of irAEs requiring hospitalization were higher with younger age, treatment with combination ICI therapy (cytotoxic T lymphocyte-associated 4 and programmed cell death protein 1 (PD-1) or programmed death-ligand 1 (PD-L1)), and lower for other cancers compared with patients on PD-1 or PD-L1 inhibitors with lung cancer. This evidence from the first nationwide study of irAEs requiring hospitalization in the USA identified the real-world epidemiology, risk factors, and treatment patterns of these irAEs which may guide treatment and management decisions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: The practice of alternating operating theatres has long been used to reduce surgeon idle time between cases. However, concerns have been raised as to the safety of this practice. We assessed the payments and outcomes of total knee arthroplasty (TKA) performed during overlapping and nonoverlapping days, also comparing the total number of the surgeon's cases and the total time spent in the operating theatre per day., Materials and Methods: A retrospective analysis was performed on the Centers for Medicare & Medicaid Services (CMS) Limited Data Set (LDS) on all primary elective TKAs performed at the New England Baptist Hospital between January 2013 and June 2016. Using theatre records, episodes were categorized into days where a surgeon performed overlapping and nonoverlapping lists. Clinical outcomes, economic outcomes, and demographic factors were calculated. A regression model controlling for the patient-specific factors was used to compare groups. Total orthopaedic cases and aggregate time spent operating (time between skin incision and closure) were also compared., Results: A total of 3633 TKAs were performed (1782 on nonoverlapping days; 1851 on overlapping days). There were no differences between the two groups for length of inpatient stay, payments, mortality, emergency room visits, or readmission during the 90-day postoperative period. The overlapping group had 0.74 fewer skilled nursing days (95% confidence interval (CI) -0.26 to -1.22; p < 0.01), and 0.66 more home health visits (95% CI 0.14 to 1.18; p = 0.01) than the nonoverlapping group. On overlapping days, surgeons performed more cases per day (5.01 vs 3.76; p < 0.001) and spent more time operating (484.55 minutes vs 357.17 minutes; p < 0.001) than on nonoverlapping days., Conclusion: The study shows that the practice of alternating operating theatres for TKA has no adverse effect on the clinical outcome or economic utilization variables measured. Furthermore, there is opportunity to increase productivity with alternating theatres as surgeons with overlapping cases perform more cases and spend more time operating per day. Cite this article: Bone Joint J 2019;101-B:1081-1086.

Background: There are few studies available on the savings generated and strategies employed for cost reduction in total joint arthroplasty. In this study, our organization-a group of private practices partnering with a consultant-aimed to analyze the impact of a preoperative protocol on overall cost savings., Materials and Methods: Using administrative data from the Medicare Bundled Payments for Care Improvement (BPCI) initiative, 771 consecutive total joint arthroplasty patients from 2009-2014 were compared with 408 consecutive BPCI patients from 2014-2017. The 30-day episode and Medicare part B total cost of care was analyzed. This included inpatient and post-discharge expenditure, laboratory and imaging costs, physician and ER visits, and readmission., Results: Average total episode cost declined by $3,174 or 13% from $23,925 to $20,752 (p<0.001) in the BPCI period. Readmission rate was unchanged (p=0.20), and there was a 48% reduction in the percent of patients presenting to the emergency room (p=.03). There was a decline of $2,647 (78%) in skilled nursing cost per case, which represented the majority of savings. Post-discharge imaging, laboratory test claims, postoperative emergency room visits, primary care physician (PCP) visits, and cost per episode all decreased. The decrease in PCP utilization did not result in increased medical complications or readmissions., Conclusion: Our preoperative patient-education protocol has decreased non-home discharge, unnecessary postoperative physician visits, and diagnostic testing resulting in an episode cost savings of 13%. With Advanced BPCI on the horizon, orthopedic surgeon control as the awardee of the bundle, combined with an increasing focus on patient education, will continue to lower costs and improve patient care.

Impulse peak insertion loss (IPIL) was studied with two acoustic test fixtures and four hearing protector conditions at the E-A-RCAL Laboratory. IPIL is the difference between the maximum estimated pressure for the open-ear condition and the maximum pressure measured when a hearing protector is placed on an acoustic test fixture (ATF). Two models of an ATF manufactured by the French-German Research Institute of Saint-Louis (ISL) were evaluated with high-level acoustic impulses created by an acoustic shock tube at levels of 134 decibels (dB), 150 dB, and 168 dB. The fixtures were identical except that the E-A-RCAL ISL fixture had ear canals that were 3 mm longer than the National Institute for Occupational Safety and Health (NIOSH) ISL fixture. Four hearing protection conditions were tested: Combat Arms earplug with the valve open, ETYPlugs ® earplug, TacticalPro headset, and a dual-protector ETYPlugs earplug with TacticalPro earmuff. The IPILs measured for the E-A-RCAL fixture were 1.4 dB greater than the National Institute for Occupational Safety and Health (NIOSH) ISL ATF. For the E-A-RCAL ISL ATF, the left ear IPIL was 2.0 dB greater than the right ear IPIL. For the NIOSH ATF, the right ear IPIL was 0.3 dB greater than the left ear IPIL.

The Dietary Goals for the United States were introduced in 1977 and have been followed by the Dietary Guidelines for Americans (DGA) every 5 years from 1980 to 2010. The DGA provide science-based advice to promote health and reduce risk for major chronic diseases through diet and physical activity. The Dietary Guidelines Advisory Committees are charged to provide updates of the DGA topics using the best available science. The Dietary Guidelines Advisory Committees' reports also identified 169 research gaps. To date, these gaps have not been compiled and assessed. We evaluated trends in number, topics, and specificity of research gaps by year by placing them in the following topic categories: general, chronic diseases/conditions, diet/diet pattern, food/ingredient, and nutrient-specific research gaps. Some research topics (eg, sodium and hypertension and appropriate uses of DGA) have been identified consistently across the years, some emerged in later years (eg, increasingly specific research gaps between dietary fatty acids and cardiovascular disease), and others appeared intermittently (eg, relationships between dietary components and cancer). These results are a call to action for all DGA stakeholders to have an immediate dialogue about how the research enterprise can best address critical research needs in a timely way to support public policy., (Copyright © 2013 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Objectives: To provide hearing threshold percentiles from unscreened older adults for creating new Annex B reference standards., Design: Percentiles are calculated, and 95% confidence intervals for medians from two U.S. surveys are compared graphically., Results: Median thresholds are lower (better) in the 1999-2006 National Health and Nutrition Examination Survey for men across all frequencies except 1 kHz. Results for women are similar; however, there is more overlap in confidence intervals across frequencies., Conclusions: The prevalence of hearing impairment in older adults, age 70 years (65-74 years), is lower in 1999-2006 compared with 1959-1962, consistent with our earlier findings for younger adults.