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Introduction: Blood loss following total knee arthroplasty can lead to substantial morbidity and the need for blood transfusions. Hemostatic agents have been used to minimize blood loss and to decrease transfusion rates. Floseal is a thrombin-based hemostatic agent with unknown efficacy for achieving these goals in patients undergoing total knee arthroplasty.Methods: We performed a prospective randomized controlled trial on the use of Floseal in patients undergoing total knee arthroplasty, with the primary end point being blood loss as measured through drain output. Demographic characteristics, operative side, diagnosis, intraoperative details, implant choice, hospital course, laboratory values, visual analog scale pain scores, knee range of motion, adverse events, transfusion rates, and deviations from protocol were recorded.Results: A total of 196 patients were enrolled, with ninety-seven patients being randomized to the Floseal group and ninety-nine patients being randomized to the control group. There were no significant differences between the Floseal and control groups in terms of drain output at twenty-four hours (711 compared with 702 mL; p = 0.823). No differences were noted between the groups in terms of operative side, diagnosis, intraoperative details, implant choice, hospital course, laboratory values, visual analog scale pain scores, knee range of motion, or transfusion rates. Complications occurred infrequently. In the acute postoperative period, there were two cases of cellulitis (one in each group), two deep venous thromboses (one in each group), and one paralytic ileus (in the control group), all of which resolved with nonoperative measures. At the six-week follow-up, one patient in the Floseal group had died from a cause unrelated to surgery, two patients (one in each group) had suture abscesses with cellulitis that resolved with postoperative antibiotics, and four patients (two in each group) underwent knee manipulation under anesthesia to achieve improved knee motion. With the numbers available, there was no significant association between Floseal use and the occurrence of these adverse events.Conclusions: The present study showed that Floseal had no demonstrable effect on blood loss as measured through drain output following total knee arthroplasty. There were also no notable adverse events associated with its use. The usefulness of Floseal as a hemostatic agent in total knee arthroplasty remains unclear. [ABSTRACT FROM AUTHOR]

Effective partnerships between local and state public health agencies and schools of public health have tremendous potential to improve the health of communities nationwide. This article highlights successful collaboration between local public health agencies (LPHA), state health departments, and Academic Centers for Public Health Preparedness (ACPHP) in schools of public health developed through participation in Project Public Health Ready, a program to recognize LPHA emergency preparedness. The project's pilot phase illustrated that LPHAs, state health departments, and ACPHP can effectively work together to improve individual public health worker competency and organizational response capacity in local public health agencies nationwide. [ABSTRACT FROM AUTHOR]

State and local collaboration is critical to effective preparedness and response planning. Through various assessments, the National Association of County and City Health Officials (NACCHO) is tracking the way in which local and state public health agencies are coordinating their planning efforts to ensure adequate bioterrorism and emergency response capacities. NACCHO's analysis of planning provides a case study of effective and ineffective collaboration. NACCHO intends to share these lessons to provide local and state public health agencies with strategies for enhancing collaboration in the future. [ABSTRACT FROM AUTHOR]

Hepatitis C virus (HCV) infection is the most common bloodborne infection in the United States. To determine the capacity of local health departments to respond to concerns about HCV, local health officers were surveyed regarding HCV programs and needs. Of 612 respondents, fewer reported offering HCV services (education, counseling, testing) compared with those for HIV. Most respondents reported that technical assistance would be needed for HCV services and that such services should be integrated into existing HIV programs. Many local health departments may be unprepared for a growing need for public HCV services; integrated HCV-HIV programs should be considered. [ABSTRACT FROM AUTHOR]

Competing Interests: The authors declare no conflicts of interest.

Boat Harbour, Nova Scotia was a tidal estuary that was converted into a wastewater treatment facility for pulp mill effluent in 1967. Treated effluent from Boat Harbour was discharged into the coastal Northumberland Strait, contributing significant nutrient and freshwater inputs into the coastal environment, potentially impacting local biogeochemistry and ecosystem structure. This study used stable isotope analysis of carbon (δ 13 C) and nitrogen (δ 15 N) of representative taxa to assess spatial variability in nutrient sources and trophic dynamics. Results identified stable isotope variation with depleted δ 13 C and δ 15 N values in taxa near Boat Harbour. Blue mussel (Mytilus edulis) and mummichog (Fundulus heteroclitus) were the most suitable bioindicators for identifying variation in nutrient sources. Stable isotope signatures in this study may be reflective of residual pulp mill effluent-derived nutrients, differences in marine versus terrestrial nutrient sources, and a pronounced coastal salinity gradient. The present study defined the baseline nutrient conditions of the Northumberland Strait and will be useful in assessing the effectiveness of remediation activities., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

State and territorial health officials (STHOs) play a critical role in leading public health emergency response in their respective states. Through an exploratory qualitative study with 21 current or former STHOs, we sought to understand the issues that impact STHO decision making in public health responses. Initial findings suggest the need for structured decision making tools for use by leaders responding to public health emergencies, including COVID-19. Such tools could lead to more systematic responses by STHOs during public health crises., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Context: State and territorial health agencies can optimize programmatic funding through braiding and layering strategies., Implementation: The Commonwealth Healthcare Corporation, a territorial health agency located on the Pacific Island of Saipan, Commonwealth of the Northern Mariana Islands (CNMI), restructured its Non-Communicable Disease Bureau into 4 new units. Existing funding streams were braided and layered to support the restructuring. A shared vision of strengthening crosscutting connections to improve population health outcomes helped guide the restructuring process. Vision planning with leaders and funding partners, establishing buy-in within agency and external partners, and assessing immediate impacts were a few of the steps taken by the agency to ensure a successful restructuring., Impact: The immediate impact of the restructure has been positive. In both the CNMI and select states that have undertaken similar efforts, braiding and layering funding has facilitated more streamlined processes, coordinated approaches across programs and funding partners, and provided deeper levels of trust in partnerships. Although it is still too early to draw long-term assessments in the CNMI, the agency projects that coordinated funds will strengthen its foundational capabilities and promote a more community-centered, collaborative, and effective approach to public health. Restructuring the Non-Communicable Disease Bureau through braiding and layering funds gives the agency the flexibility it needs to more effectively address the social determinants of health and local population health priorities through a client-centered approach, ultimately improving health outcomes for the commonwealth., Lessons Learned and Implications: The agency experienced several challenges throughout the restructuring process that offer lessons learned for addressing effective health financing. For example, ample time is needed at the beginning of the braiding and layering process to establish policies and procedures for efficient accounting, documenting, and reporting. In addition, ongoing support and training opportunities for programmatic teams can smooth out the transition from siloed to braided and layered funding structures. These lessons, in addition to key elements mapped out by experienced state health agencies, can guide and prepare other agencies interested in implementing innovative funding mechanisms., Competing Interests: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Cortical tau accumulation is a key pathological event that partly defines Alzheimer's disease (AD) onset and is associated with cognitive decline and future disease progression. However, an improved understanding of the timing and pattern of early tau deposition in AD and how this may be tracked in vivo is needed. Data from 59 participants involved in two longitudinal cohort studies of autosomal dominant AD (ADAD) were used to investigate whether tau PET can detect and track presymptomatic change; seven participants were symptomatic, and 52 were asymptomatic but at a 50% risk of carrying a pathogenic mutation. All had baseline flortaucipir (FTP) PET, MRI and clinical assessments; 26 individuals had more than one FTP PET scan. Standardised uptake value ratios (SUVRs) in prespecified regions of interest (ROIs) were obtained using inferior cerebellar grey matter as the reference region. We compared the changes in FTP SUVRs between presymptomatic carriers, symptomatic carriers and non-carriers, adjusting for age, sex and study site. We also investigated the relationship between regional FTP SUVRs and estimated years to/from symptom onset (EYO). Compared to both non-carriers and presymptomatic carriers, FTP SUVRs were significantly higher in symptomatic carriers in all ROIs tested (p < 0.001). There were no significant regional differences between presymptomatic carriers and non-carriers in FTP SUVRs, or their rates of change (p > 0.05), although increased FTP signal uptake was seen posteriorly in some individuals around the time of expected symptom onset. When we examined the relationship of FTP SUVR with respect to EYO, the earliest significant regional difference between mutation carriers and non-carriers was detected within the precuneus prior to estimated symptom onset in some cases. This study supports preliminary studies suggesting that presymptomatic tau tracer uptake is rare in ADAD. In cases where early uptake was seen, there was often a predilection for posterior regions (the precuneus and post-cingulate) as opposed to the medial temporal lobe, highlighting the importance of examining in vivo tau uptake beyond the confines of traditional Braak staging., (© 2023. The Author(s).)

Understanding the size and composition of the state and local governmental public health workforce in the United States is critical for promoting and protecting the health of the public. Using pandemic-era data from the Public Health Workforce Interests and Needs Survey fielded in 2017 and 2021, this study compared intent to leave or retire in 2017 with actual separations through 2021 among state and local public health agency staff. We also examined how employee age, region, and intent to leave correlated with separations and considered the effect on the workforce if trends were to continue. In our analytic sample, nearly half of all employees in state and local public health agencies left between 2017 and 2021, a proportion that rose to three-quarters for those ages thirty-five and younger or with shorter tenures. If separation trends continue, by 2025 this would represent more than 100,000 staff leaving their organizations, or as much as half of the governmental public health workforce in total. Given the likelihood of increasing outbreaks and future global pandemics, strategies to improve recruitment and retention must be prioritized.

In the United States, the public health response to control COVID-19 required rapid expansion of the contact tracing workforce from approximately 2200 personnel prepandemic to more than 100 000 during the pandemic. We describe the development and implementation of a free nationwide training course for COVID-19 contact tracers that launched April 28, 2020, and summarize participant characteristics and evaluation findings through December 31, 2020. Uptake of the online asynchronous training was substantial: 90 643 registrants completed the course during the first 8 months. In an analysis of a subset of course participants (n = 13 697), 7724 (56.4%) reported having no prepandemic public health experience and 7178 (52.4%) reported currently serving as case investigators, contact tracers, or both. Most participants who completed a course evaluation reported satisfaction with course utility (94.8%; 59 497 of 62 753) and improved understanding of contact tracing practice (93.0%; 66 107 of 71 048). These findings suggest that the course successfully reached the intended audience of new public health practitioners. Lessons learned from this implementation indicate that an introductory course level is appropriate for a national knowledge-based training that aims to complement jurisdiction-specific training. In addition, offering a range of implementation options can promote course uptake among public health agency staff. This course supported the emerging needs of the public health practice community by training a workforce to fill an important gap during the COVID-19 pandemic and could serve as a feasible model for enhancing workforce knowledge for future and ongoing public health threats.

Competing Interests: The authors declare no conflicts of interest.

Competing Interests: The authors declare no conflicts of interest.

Mutations in the Presenilin 1 (PSEN1) gene are the most common cause of autosomal dominant familial Alzheimer's disease. We report the clinical, imaging and postmortem findings of kindred carrying a novel duplication mutation (Ile168dup) in the PSEN1 gene. We interpret the pathogenicity of this novel variant and discuss the additional neurological features (pyramidal dysfunction, myoclonus and seizures) that accompanied cognitive decline. This report broadens the clinical phenotype of PSEN1 insertion mutations while also highlighting the importance of considering duplication, insertion and deletion mutations in cases of young onset dementia., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Containing coronavirus disease 2019 (COVID-19) through case investigation and contact tracing is a crucial strategy for governmental public health agencies to control the spread of COVID-19 infection in the United States. Because of the recency of the pandemic, few examples of COVID-19 contact-tracing models have been shared among local, state, and federal public health officials to date. This case study of the Anne Arundel County Department of Health (Maryland) illustrates one model of contact-tracing activity developed early in the outbreak. We describe the contact-tracing effort's place within the broader county health agency Incident Command System, as well as the capabilities needed, team composition, special considerations, and major lessons learned by county health officials. Other local, state, tribal, territorial, and federal health officials and policy makers can use this case study to innovate, iterate, and further refine contact-tracing efforts to prevent the spread of COVID-19 infection and support community members in isolation or quarantine.

Context: Case investigation and contact tracing are fundamental public health strategies for controlling and preventing the spread of infectious diseases. Although the principles behind these strategies are not new, the capacity and operational requirements needed to support disease investigation during the SARS-CoV-2 (COVID-19) pandemic are unprecedented. This article analyzes the implementation of case investigation and contact tracing in controlling COVID-19 transmission during the early stages of the US pandemic response (January 20 through August 31, 2020)., Program Implementation: Governmental public health agencies mobilized to expand case investigation and contact tracing programs in the early months of the pandemic. In doing so, they encountered a range of challenges that included rapidly scaling up the workforce; developing and subsequently revising guidance and protocols specific to COVID-19 as more was learned about the virus over time; defining job functions; encouraging public acceptance of and participation in case investigation and contact tracing; and assessing the utility of these activities during both the containment and mitigation phases of outbreak response. COVID-19 case investigation and contact tracing programs presented an array of opportunities for health departments to innovate, especially around technology to support public health efforts, as well as opportunities to address health equity and advance community resilience., Conclusion: Lessons learned from disease intervention specialists, guidance and resources from federal agencies and national partners, and peer-to-peer exchange of promising practices can support jurisdictions encountering early implementation challenges. Further research is needed to assess COVID-19 case investigation and contact tracing program models and innovations, as well as strategies for implementing these activities during containment and mitigation phases.

US states and big cities acted to protect the residents of their jurisdictions from the threat of SARS-CoV-2 infection and reduce COVID-19 transmission. As there were no known pharmacologic interventions to prevent COVID-19 at the outset of the pandemic, public health and elected leaders implemented a host of nonpharmaceutical interventions (NPIs) to slow the spread of the virus. This article discusses variation among states and cities in their implementation of 3 NPIs: stay-at-home/shelter-in-place orders, gathering restrictions, and mask mandates. We illustrate how frequently each was used by states and big cities, discuss state and local authorities to implement such interventions, and consider how these NPIs and accompanying public adherence to public health orders may vary considerably in different regions of the country and by local and state laws specific to state preemption of public health authority.

The nation's first broad-based, mandatory investment in public health and prevention, the Prevention and Public Health Fund (the Fund), has had a brief and controversial history. Advocates for the Fund have had to defend it from both Democratic and Republican threats, including being used as an offset for administration priorities, and from congressional efforts to repeal and replace the Patient Protection and Affordable Care Act. Lessons learned from efforts to sustain the Fund are instructive in addressing current and future challenges faced by advocates for public health programs and prevention policies.

Case: When a 31-year-old man with no prior medical history underwent diagnostic arthroscopy for posttraumatic knee pain, ochronotic arthropathy was identified. Subsequent blood tests led to the diagnosis of alkaptonuria. After a discussion regarding his future military career and prognosis, he elected to proceed with osteochondral allograft transplantation surgery (OATS). He was able to return to active-duty service with minimal knee pain. At the 32-month postoperative visit, he had functional, pain-free motion and an excellent Hospital for Special Surgery (HSS) knee score., Conclusion: Alkaptonuria is an uncommon metabolic disorder that causes arthropathy of peripheral joints. When there is a focal defect, an osteochondral allograft is a valid, joint-preserving option that allows return to activity.

Effective maternal and child health (MCH) practice requires skillfully combining a number of theoretical models and frameworks to support systems addressing the health needs of women, children, and families. This paper describes three perspectives relevant to current MCH practice: the federal Maternal & Child Health Bureau's Pyramid of MCH Health Services [1], Frieden's Health Impact Pyramid [Frieden in Am J Public Health 100(4):590-595, (2010)], and life course theory [Halfon in Milbank Quart, 80:433-79, (2002); Kotelchuck in Matern Child Health J, 7:5-11, (2003); Pies (2009)], an emerging conceptual framework that addresses a number of pressing maternal and child health issues including health disparities and the social determinants of health. While developed independently, a synthesis of these three frameworks provides an important analytical perspective to assess the adequacy and comprehensiveness of current public health programs and systems supporting maternal and child health improvement. Synthesizing these frameworks from the specific vantage point of MCH practice provides public health practitioners with important and dynamic opportunities to promote improvements in health, especially for state and local governmental health agencies with the statutory authority and public accountability for improving the health of women, children, and families in their jurisdictions. A crucial finding of this synthesis is that significant improvements in MCH outcomes at the state and local levels are the result of collaborative, integrated, and synergistic implementation of many different interventions, programs and policies that are carried out by a number of stakeholders, and administered in many different settings. MCH programs have a long history of coordinating disparate sectors of the health care and public health enterprise to create systems of services that improve maternal and child health. Future improvements in MCH build on this legacy but will come from a "paradigm shift" in MCH practice that blends (1) evidence-based interventions and best practices that improve the health of individuals, communities, and populations, and crosscuts health service settings with (2) public policies that promote and improve maternal and child health needs at the local, state, and national levels, and (3) supports MCH leadership to implement such changes in MCH systems nationwide. As such, the challenge presented by this synthesis is not merely technical, i.e. having the scientific and organizational capacity to address identified MCH needs. Instead, a more pressing challenge is providing effective leadership in the coordination and integration of these frameworks and using them in practice to develop a vision that guides programs and policies to improve maternal and child health nationwide.

Background: Placement of external fixation frames is an expedient and minimally invasive method of achieving bone and joint stability in the setting of severe trauma. Although anatomic safe zones are established for placement of external fixation pins, neurovascular structures may be at risk in the setting of severe trauma., Case Report: We present a case of a 21-year-old female involved in a high speed motorcycle accident who sustained a Type IIIB open segmental femur fracture with significant thigh soft tissue injury. Damage control orthopedic principals were applied and a spanning external fixator placed for provisional femoral stabilization. Intraoperative vascular examination noted absent distal pulses, however an intraoperative angiogram showed arterial flow distal to the trifurcation. Immediately postoperatively the dorsalis pedis pulse was detected using Doppler ultrasound but was then non-detectable over the preceding 12-hours. Femoral artery CT angiogram revealed iatrogenic superficial femoral artery occlusion due to kinking of the artery around an external fixator pin. Although the pin causing occlusion was placed under direct visualization, the degree of soft tissue injury altered the appearance of the local anatomy. The pin was subsequently revised allowing the artery to travel in its anatomic position, restoring perfusion., Conclusion: This case highlights the dangers associated with damage control orthopedics, especially when severe trauma alters normal local anatomy. Careful assessment of external fixator pin placement is crucial to avoiding iatrogenic injury. We recommend a thorough vascular examination pre-operatively and prior to leaving the operating room, which allows any abnormalities to be further evaluated while the patient remains in a controlled environment. When an unrecognized iatrogenic injury occurs, serial postoperative neurovascular examinations allow early recognition and corrective actions.

Pseudopseudohypoparathyroidism (PPH) is a rare genetic disorder characterized by multiple musculoskeletal anomalies and normal serum calcium, phosphate, and parathyroid hormone levels. Although the musculoskeletal manifestations of PPH are well known, little has been reported on the management of orthopedic problems. We report a case of total knee arthroplasty (TKA) performed in a patient with PPH. To our knowledge, this case is not only unique to the arthroplasty literature but is the first report of its kind. This report illustrates the unique pathoanatomy of PPH, the medical and surgical management required, and a previously unreported musculoskeletal abnormality associated with PPH: synovial osteochondromatosis of the knee. Common musculoskeletal anomalies associated with PPH include shortening/bowing of long bones; shortening of metacarpals, metatarsals, and/or phalanges; exostoses; calcification/ossification of subcutaneous and/or periarticular soft tissues; a thickened calvarium; microcephaly; bony coalitions of the hand; vertebral column abnormalities; cubitus valgus; radius/ulna curvus; coxa vara; coxa valga; and genu valgum. This case is the first to report an association of synovial osteochondromatosis with PPH. Because synovial osteochondromatosis and PPH share a common disorder of soft tissue calcification/ossification, as well as abnormal bone formation, this clinical finding does not seem merely coincidental., (Copyright 2011, SLACK Incorporated.)

There is a paucity of information about the nation's local governmental public health agency (LPHA) workforce. Without additional research, crucial questions about the individuals providing front-line public health services remain unanswered. Current national efforts to develop a public health workforce research agenda must include strategies for collecting basic data on local governmental public health workers. The work of enumerating and classifying LPHA staff is complicated, but not impossible. Projects to improve LPHA performance and discussions of the certification of public health workers are incomplete without current and accurate data on the individuals comprising our nation's public health system. The need to describe basic facets of the LPHA workforce is not trivial. As city and county budgets are cut and LPHAs are left scrambling to cover lost positions, data are needed to inform important decisions about what kinds of LPHA staff are needed to keep a community healthy.

Research addressing "environmental equity" and "environmental racism" claims that facilities for treatment, storage, and disposal of hazardous wastes (TSDFs) are located disproportionately in minority areas. In the first comprehensive study of TSDFs to use census tract-level data, we find no nationally consistent and statistically significant differences between the racial or ethnic composition of tracts which contain commercial TSDFs and those which do not. TSDFs are more likely to be found in tracts with Hispanic groups, primarily in regions with the greatest percentage of Hispanics. Different geographic units of analysis elaborate on, but are consistent with, these results.