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Introduction: The 75th Ranger Regiment is an elite U.S. military special operations unit that conducted over 20 years of sustained combat operations. The Regiment has a history of providing novel and cutting-edge prehospital trauma care, advancing and translating medical initiatives, and documenting and reporting casualty care performance improvement efforts., Materials and Methods: A retrospective case fatality rate (CFR) review, mortality review, and descriptive analysis of fatalities were conducted for battle-injured personnel assigned or attached to the 75th Ranger Regiment from 2001 to 2021 during combat operations primarily in Afghanistan and Iraq. Fatalities were evaluated for population characteristics, cause of death, mechanism of death, injury severity, injury survivability, and death preventability., Results: A total of 813 battle injury casualties, including 62 fatalities, were incurred over 20 years and 1 month of continuous combat operations. The Regiment maintained a zero rate of prehospital preventable combat death. Additionally, no fatalities had a mechanism of death because of isolated extremity hemorrhage, tension pneumothorax, or airway obstruction. When comparing the CFR of the Regiment to the U.S. military population as a whole, the Regiment had a significantly greater reduction in the cumulative CFR as measured by the difference in average annual percentage change., Conclusions: Documentation and analysis of casualties and care, mortality and casualty reviews, and other performance improvement efforts can guide combatant commanders, medical directors, and fighting forces to reduce preventable combat deaths and the CFR. Early hemorrhage control, blood product resuscitation, and other lifesaving interventions should be established and maintained as a standard prehospital practice to mitigate fatalities with potentially survivable injuries., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Severe food selectivity places children at risk for nutrient deficiencies and long-term medical complications, if unaddressed. However, poor nutrition in highly selective eaters is often overlooked when considering other behavioral or medical concerns. Additionally, studies regarding food selectivity are sparse and limited to children with developmental delays. This study further investigates the nutritional deficiencies and growth characteristics of children with severe food selectivity to assist pediatricians in the earlier identification of patients for nutrition screening. A retrospective chart review was completed for 13 patients admitted to a pediatric feeding program solely for table-textured food selectivity. Nutrition and anthropometric data from the medical record were analyzed. All patients were determined to be following an age-appropriate growth curve but had multiple micronutrient deficiencies. Additionally, 6 children were typically developing outside of the feeding context. Results suggest that children with food selectivity may require more intensive and earlier nutrition screening beyond their growth patterns., Competing Interests: Dr Drayton and Dr Knight are NASPGHAN members. Other authors report no conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Droplet charging is an effective method to enhance dust removal efficiency using an electrostatic spray scrubber (ESS). However, effects of the materials and dimensions of different electrodes on droplet charging efficiency have not been studied systematically. In this study, ring-shaped electrodes were selected to test effects of three types of electrode materials (copper, stainless steel, and graphite) with various dimensions on droplet charging efficiency. A Faraday pail charge measurement device was used to measure the droplet charge generated by the electrodes. A reduced factorial design with four factors was used in this study to investigate the charging efficiency affected by the factors. The four factors tested were electrode material, electrode diameter, nozzle height, and applied voltage. A 304L stainless steel electrode was found to achieve higher droplet charge-to-mass ratio (CMR) values than identically shaped electrodes made from either copper or graphite. The optimal stainless steel electrode inner diameter was 100 mm. The 304L stainless-steel electrode with this optimal diameter and a height of 45 mm achieved the highest mean CMR of 0.435 ± 0.002 mC kg -1 at an applied voltage of -11 kV with the bottom of the nozzle tip positioned 15 mm below the top of the electrode. Implications Currently, the low removal efficiency of submicron particles cannot meet the environmental control requirements of industrial applications that may have significant concentrations of particulate matter (PM) in this size range. As stricter environmental regulations are increasingly enforced, there is an urgent need to efficiently remove submicron dust particles from the air. Experiments show that the dust capture process is improved by charging droplets in the spray separator and reducing the secondary escape of dust particles in the electrostatic precipitatorAlthough high-voltage charging of droplets has been investigated in many studies, the effect of electrode material and size on droplet CMR is still not fully understood. The purpose of this study was to (1) quantify the performance of 304L stainless steel (304L SS), copper, and high-purity graphite electrodes for spray droplet CMR, (2) evaluate effects of the applied voltage, nozzle height, electrode material and dimension on CMR, and (3) optimize the specific values of key design factors and operating parameters that lead to the highest CMR. The results of this study aim to optimize electrostatic spray scrubbers to achieve high droplet CMR values.

Objectives: Neonates undergoing cardiac surgery are at risk for oral aversion (OA). OA is not well described outside of the index hospitalization and impacts patients and families. We evaluated the prevalence of OA at 1 year old after neonatal cardiopulmonary bypass (CPB) surgery., Design: Retrospective cohort study., Setting: Single quaternary care hospital., Subjects: Our cohort included 157 neonates who underwent CPB surgery from 2014 to 2017 and had follow-up data available at 1 year old., Interventions: None., Measurements and Main Results: Three feeding experts reviewed the medical record to define children with OA; 30% of charts were evaluated in triplicate for validation. Neonates with and without OA were compared in univariate analysis, and risk factors for OA were explored in a limited multivariable analysis. OA was present at 1 year in 37 patients (23.6%) and other feeding difficulties were present in an additional 29 patients (18.5%). Thirty-eight patients (24.2%) had a feeding tube, including 12 (7.6%) with a gastrostomy tube. Factors associated with OA at 1 year included total ICU days, duration of mechanical ventilation, total number of nil per os days, and number of postoperative days (PODs) until oral feeding initiation (all p < 0.0001). Number of POD until oral feeding initiation remained independently associated with OA at 1 year in multivariable analysis (adjusted odds ratio, 1.08; 95% CI, 1.04-1.12; p < 0.0001). Infants with any oral intake at discharge had lower odds of OA at 1 year (0.21; 95% CI, 0.08-0.5; p = 0.0003). At hospital discharge, 132 patients (84.1%) were taking some oral feeds, and 128 patients (81.5%) received tube feeding., Conclusions: OA and other feeding difficulties are common at 1 year old in neonates undergoing CPB surgery. Delayed exposure to oral intake may be a modifiable risk factor for OA and efforts to improve early oral feeding could lead to better functional outcomes., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Hemorrhagic shock in combat trauma remains the greatest life threat to casualties with potentially survivable injuries. Advances in external hemorrhage control and the increasing use of damage control resuscitation have demonstrated significant success in decreasing mortality in combat casualties. Presently, an expanding body of literature suggests that fluid resuscitation strategies for casualties in hemorrhagic shock that include the prehospital use of cold-stored or fresh whole blood when available, or blood components when whole blood is not available, are superior to crystalloid and colloid fluids. On the basis of this recent evidence, the Committee on Tactical Combat Casualty Care (TCCC) has conducted a review of fluid resuscitation for the combat casualty who is in hemorrhagic shock and made the following new recommendations: (1) cold stored low-titer group O whole blood (CS-LTOWB) has been designated as the preferred resuscitation fluid, with fresh LTOWB identified as the first alternate if CS-LTOWB is not available; (2) crystalloids and Hextend are no longer recommended as fluid resuscitation options in hemorrhagic shock; (3) target systolic blood pressure (SBP) resuscitation goals have been redefined for casualties with and without traumatic brain injury (TBI) coexisting with their hemorrhagic shock; and (4) empiric prehospital calcium administration is now recommended whenever blood product resuscitation is required., (2021.)

Early tranexamic acid (TXA) administration for resuscitation of critically injured warfighters provides a mortality benefit. The 2019 Tactical Combat Casualty Care (TCCC) recommendations of a 1g drip over 10 minutes, followed by 1g drip over 8 hours, is intended to limit potential TXA side effects, including hypotension, seizures, and anaphylaxis. However, this slow and cumbersome TXA infusion protocol is difficult to execute in the tactical care environment. Additionally, the side effect cautions derive from studies of elderly or cardiothoracic surgery patients, not young healthy warfighters. Therefore, the 75th Ranger Regiment developed and implemented a 2g intravenous or intraosseous (IV/IO) TXA flush protocol. We report on the first six cases of this protocol in the history of the Regiment. After-action reports (AARs) revealed no incidences of post-TXA hypotension, seizures, or anaphylaxis. Combined, the results of this case series are encouraging and provide a foundation for larger studies to fully determine the safety of the novel 2g IV/IO TXA flush protocol toward preserving the lives of traumatically injured warfighters., (2020.)

Soy-based foods are consumed for their health beneficial effects, implying that the population is exposed to soy isoflavones in the diet. Herein, male rats at 21, 35, and 75 days of age were maintained either on a casein control diet, soybean meal (SBM), or control diet supplemented with daidzin and genistin (G + D) for 14 days. Feeding of SBM and G + D diets decreased testicular testosterone (T) secretion regardless of age. Altered androgen secretion was due to decreased (P < 0.05) Star and Hsd17β protein in the testes and was associated with increased (P < 0.05) Lhβ and Fshβ subunit protein expression in pituitary glands. Second, male rats were fed either a casein control diet, control diet + daidzin, control diet + genistin, or control diet + genistin + daidzin (G + D). Compared to control, feeding of all isoflavone-containing diets decreased (P < 0.05) testicular T concentrations, and more so in the G + D diet group. Interestingly, Esr1 and androgen receptor protein and pituitary Fshβ with Lhβ subunit protein were increased (P < 0.05) by feeding of genistin and G + D diets, but not the daidzin diet. However, daidzein and genistein both caused a concentration dependent inhibition (P < 0.05) of T secretion by Leydig cells in vitro with IC50 of 184 ηM and 36 ηM, respectively. Results demonstrated that altered testicular steroidogenic capacity and pituitary FSHβ and LHβ subunit expression due to soy-based diets result from specific actions by genistein and daidzein. Experiments to assess effects of isoflavone regulation of intratesticular androgen concentrations on male fertility are warranted., (© The Author(s) 2020. Published by Oxford University Press on behalf of Society for the Study of Reproduction. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

We present the case of a severely injured Special Operations Servicemember whose care was remarkable for three unique interventions: the first use of a walking blood bank performed at the point of injury, prolonged permissive hypotension, and intermittent resuscitative endovascular balloon occlusion of the aorta (REBOA)., (2020.)

Objective: Time-out is a widely used child discipline strategy and one of the only strategies currently recommended by the American Academy of Pediatrics. Despite its widespread use and significant evidence to support its effectiveness in decreasing problem behavior, time-out is often suggested to be harmful or ineffective by the popular media and select professional organizations. Empirical evidence regarding possible side effects of time-out is limited. The present study examined the relationship between reported use of time-out and child emotional and behavioral functioning and parent-child relationships using longitudinal, archival data., Methods: The study used archival, longitudinal data from the Early Head Start Research and Evaluation study. This study tracked families with children in Early Head Start at 3 different time points as follows: baseline (aged 0-3 years), pre-kindergarten, and fifth grade. Parent interviews, including questions on the use of time-out, were conducted when the children were 36 months old. Indicators of child emotional and behavioral health were measured at 36 months, pre-K, and fifth grade. Statistical analyses were completed to assess for potential side effects of time-out on child behavioral and emotional functioning and parent-child relationships., Results: Analyses for all outcome variables suggest no significant difference for children whose parents reported using time-out versus those who did not., Conclusion: Parental reported use of time-out was not associated with long-term negative outcomes. Further research in this area is necessary to continue to address the multitude of concerns related to time-out that are presented by the media.

Objectives: Behavioral intervention is the only treatment for pediatric feeding problems with well documented empirical support. However, parents may be hesitant to pursue behavioral intervention because of concerns about possible negative side effects on child behavioral health and the parent-child relationship. This study investigated associations between behavioral feeding treatment and parenting stress, internalizing and externalizing behavior problems in young children, and parent-child attachment quality., Methods: Participants included 16 mother-child dyads seeking treatment from a behavioral feeding clinic at a large Midwestern university medical center. Children were between the ages of 30 and 45 months (adjusted) at baseline. Caregivers completed the Child Behavior Checklist for ages 1.5 to 5 (CBCL/1.5-5), the Parenting Stress Index, 3rd Edition Short Form (PSI/SF), and mother-child dyads participated in the Strange Situation procedure at baseline and again after 6 months. The treatment group (n = 12) began outpatient behavioral feeding intervention following the baseline evaluation, whereas the control group (n = 12) remained on the clinic waitlist until after the 6-month follow-up., Results: The treatment group demonstrated decreases in internalizing and externalizing child behavior problems and parenting stress compared with the control group. No significant differences were demonstrated in parent-child attachment quality within or between groups., Conclusions: Behavioral feeding intervention had positive effects on perceptions of child emotional and behavioral functioning and maternal parenting stress. Intervention also did not impact the quality of the mother-child attachment relationship. Further research with a larger sample size and additional observational measures of behavior is needed to support the replicability and generalizability of these results.

Effectively and rapidly controlling significant junctional hemorrhage is an important effort of Tactical Combat Casualty Care (TCCC) and can potentially contribute to greater survival on the battlefield. Although the US Food and Drug Administration (FDA) has approved labeling of four devices for use as junctional tourniquets, many Special Operations Forces (SOF) medics do not carry commercially marketed junctional tourniquets. As part of ongoing educational improvement during Special Operations Combat Medical Skills Sustainment Courses (SOCMSSC), the authors surveyed medics to determine why they do not carry commercial tourniquets and present principles and methods of improvised junctional tourniquet (IJT) application. The authors describe the construction and application of IJTs, including the use of available pressure delivery devices and emphasizing that successful application requires sufficient and repetitive training., (2019.)

Feeding disorders often present in children with complex medical histories as well as those with neurodevelopmental disabilities. If untreated, feeding problems will likely persist and may lead to additional developmental and medical complications. Treatment of pediatric feeding disorders should involve an interdisciplinary team, but the core intervention should include behavioral feeding techniques as they are the only empirically supported therapy for feeding disorders., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has a place in civilian trauma centers in the United States, and British physicians performed the first prehospital REBOA, proving the concept viable for civilian emergency medical service. Can this translate into battlefield REBOA to stop junctional hemorrhage and extend "golden hour" rings in combat? If yes, at what level is this procedure best suited and what does it entail? This author's perspective, after treating patients on the battlefield and during rotary wing evacuation, is that REBOA may have a place in prehospital resuscitation but patient and provider selection are paramount. The procedure, although simple in description, is quite complicated and can cause major physiologic changes best dealt with by experienced providers. REBOA is incapable of extending the golden hour limiting the procedure's utility., (2017.)

Military prehospital providers frequently have to make important clinical decisions with only limited objective information and vital signs. Because of this, accurate estimation of blood loss, at the point of injury, can augment any available objective information. Prior studies have shown that individuals significantly overestimate the amount of blood loss when the amount of hemorrhage is small, and they tend to underestimate the amount of blood loss with larger amounts of hemorrhage. Furthermore, the type of surface on which the blood is deposited can impact the visual estimation of the amount of hemorrhage. To aid providers with the ability to accurately estimate blood loss, we took several units of expired packed red blood cells and deposited them in different ways on varying surfaces to mimic the visual impression of combat casualties., (2017.)

Objective: Pediatricians are frequently asked to address parents' behavioral concerns. Time out (TO) is one of the few discipline strategies with empirical support and is recommended by the American Academy of Pediatrics. However, correctly performed, TO can be a complex procedure requiring training difficult to provide in clinic due to time and cost constraints. The Internet may be a resource for parents to supplement information provided by pediatricians. The present study included evaluation of information on TO contained in websites frequently accessed by parents. It was hypothesized that significant differences exist between the empirically supported parameters of TO and website-based information., Methods: Predefined search terms were entered into commonly used search engines. The information contained in each webpage (n = 102) was evaluated for completeness and accuracy based on research on TO. Data were also collected on the consistency of information about TO on the Internet., Results: None of the pages reviewed included accurate information about all empirically supported TO parameters. Only 1 parameter was accurately recommended by a majority of webpages. Inconsistent information was found within 29% of the pages. The use of TO to decrease problem behavior was inaccurately portrayed as possibly or wholly ineffective on 30% of webpages., Conclusions: A parent searching for information about TO on the Internet will find largely incomplete, inaccurate, and inconsistent information. Since nonadherence to any 1 parameter will decrease the efficacy of TO, it is not recommended that pediatricians suggest the Internet as a resource for supplemental information on TO. Alternative recommendations for pediatricians are provided.

In this report, we discuss a case of a 14-month-old male presenting in the emergency department with refusal to bear weight on his left leg. Plain radiographic studies revealed no evidence of effusion, fracture, or dislocation. Laboratory studies were significant for an elevated white blood cell count, erythrocyte sedimentation rate, and C-reactive protein. Further studies included unremarkable ultrasound of the left hip and normal magnetic resonance imaging (MRI) of both hips. An incidental finding on MRI was a left inguinal mass concerning an incarcerated hernia. Ultrasound of this mass demonstrated a left undescended testis within the inguinal canal and possible incarcerated paratesticular inguinal hernia. The final pathologic diagnosis of a torsed gangrenous left testicle within the inguinal canal was confirmed during surgery.

The Rey-Osterrieth Complex Figure (ROCF; Rey 1941; Osterrieth, 1944) is frequently used in the neuropsychological assessment of children and adults. The present study was designed, in part, to examine the impact of providing organizational scaffolding to young children being tested with the ROCF. To this end, 6-, 7-, and 8-year-old children were administered the test either in the standard fashion, or using a format in which the 18 key elements of the figure were introduced sequentially. Participants included 132 children who were randomly assigned to the standard or step-by-step administration groups. Significantly higher accuracy and organization scores for both copy and recall were seen with the step-by-step format than with the standard format, even though children in the step-by-step condition took less time to execute their drawings. Retention of encoded information was not affected by age or testing format. The fact that 6-year-olds in the step-by-step condition performed as well as, or better than, 8-year-olds in the standard condition suggests that the primary problem young children experience with the ROCF lies with organizational strategy formation. Advantages of using the Step-by-step ROCF in clinical practice are discussed.

Objective: To examine the relationship between neonatal, periventricular brain damage and visuomotor performance in extremely-low-birthweight (ELBW) children of normal intelligence whose birthweights were appropriate for gestational age (AGA)., Methods: Seventy-eight ELBW and 23 control children, all six years of age, completed two "motor-free" tests of visual spatial ability and three tests requiring visuomotor control., Results: Full-term control children outperformed ELBW children with periventricular brain damage on all three tests requiring visuomotor guidance. No group differences were found on two "motor-free" tests of visual spatial ability. ELBW children without periventricular brain damage performed in a manner indistinguishable from controls on all tests included in this study., Conclusions: The findings indicate that the presence and severity of periventricular brain injury are important factors to consider in predicting visuomotor development in ELBW children.

This study was undertaken to determine the impact of an indwelling Foley catheter on bladder dysfunction and incidence of urinary tract infections after total joint arthroplasty. A prospective randomized controlled trial was conducted assigning use of an indwelling Foley catheter (group 1) or intermittent catheterization (group 2) for 48 hours following operation. Postoperative cultures were obtained on days 2 and 5, and the number of intermittent catheterization events and void and catheterization volumes were recorded. Concurrent cost-effectiveness analysis was conducted. One hundred nineteen of 174 consecutive patients having elective primary total joint arthroplasty completed the study. Five of 62 patients (8%) in group 1 and 7 of 57 patients (12%) in group 2 developed urinary tract infections (NS, P = 45). Twenty patients (35%) in group 2 and 12 (19%) in group 1 required straight catheterization for inability to void 48 hours after surgery (P = .05). Seventeen patients (35%) in group 2 and eight patients (16%) in group 1 required straight catheterization after epidural analgesia was discontinued (P = .024). Bladder management by indwelling Foley catheter saved more than 150 minutes of direct nursing contact per patient and $3,000 in total hospital costs. Indwelling Foley catheters reduced the frequency of postoperative urinary retention, were less labor intensive than intermittent straight catheterization, and were not associated with an increased risk of urinary infection. In the setting of epidural anesthesia and postoperative analgesia for total joint arthroplasty, management by indwelling catheter is a cost-effective strategy to facilitate postoperative return of normal bladder function.

To elucidate the role of axonal plasma membrane factors in the differentiation of Schwann cells, we investigated the effect of an axolemma-enriched fraction (AEF) isolated from myelinated CNS tissue on the expression of P0 glycoprotein, the major glycoprotein in peripheral myelin, in primary rat Schwann cells (PSC) isolated from sciatic nerve, as well as in a transfected rat Schwann cell line (TSC). AEF increased PO-mRNA levels in PSC and TSC in a concentration-dependent manner, producing a maximal induction of nearly twofold after 48 hr of treatment. A similar induction of P0 mRNA was elicited in TSC by the cAMP-activating agents 8-bromo-cAMP and forskolin, which have been shown to induce myelin proteins in PSC. In addition to inducing P0 mRNA, AEF and forskolin also increased the amount of P0 protein in TSC, as indicated by increased P0-immunoreactive staining. However, in TSC, axolemma caused no increase in expression of CAT linked to a P0 promoter while forskolin caused a marked increase in the expression from the P0 promoter. These results suggest that AEF, in contrast to forskolin, does not regulate P0-mRNA expression at the level of transcriptional activity. These in vitro systems may be useful for the study of axolemmal factors that induce Schwann cell differentiation.

Advanced OR nursing practice is emerging and the roles, responsibilities, relationships, and rewards are spread over preoperative, operative, and postoperative work units. The roles of the nurse in advanced practice are multidimensional: clinical, collegial, educative, investigatory, and administrative. Though the primary allegiance of the ANP is to nursing, she has a commitment and the skills to work collaboratively with other nurses and disciplines on the surgery team.

The effects of corticotropin releasing factor (CRF) on pro-opiomelanocortin (POMC) gene expression were investigated in an anterior pituitary corticotrophic tumor cell line, AtT-20/D16-16. The results of mRNA dot blot hybridization assays suggested that CRF, at a concentration of 10(-7) M, positively regulates the expression of the POMC gene in AtT-20 cells in a concentration-dependent fashion. Evaluation of the time course of this effect indicated that CRF had a biphasic mode of action. CRF and alpha-amanitin (inhibitor of RNA polymerase II activity) were also found to affect POMC mRNA levels in a concentration-dependent fashion. Eight-bromo-cyclic adenosine monophosphate (8-Br-cAMP) produced biphasic effects on POMC mRNA levels, supporting evidence of a role for cAMP as a second messenger in the regulation of POMC gene expression. It was also found that alpha-amanitin negatively regulated basal and CRF-stimulated POMC mRNA levels at both the 2 hr and 24 hr time periods, supporting evidence for positive regulation of POMC by CRF at the transcriptional level.