Cold Weather Injuries Among the Active and Reserve Components of the U.S. Armed Forces, July 2018-June 2023.

Cold injuries are a predictable and preventable threat. Continuous surveillance is essential to prevent cold weather injuries and mitigate their adverse impacts on military operations. Military training and combat operations require continued emphasis on effective cold weather injury prevention strategies and adherence to relevant policies and procedures to protect service members against such injuries. For all active component service members (ACSM), the rate of cold weather injuries in 2022-2023 decreased by 15.2% compared to the preceding cold season. The decrease was most pronounced in the Marine Corps, with a 22.0% reduction in the incidence rate of cold injuries. This year's report includes cold injury rates for the Coast Guard. From July 2022 through June 2023, a total of 423 members of the active (n=376) and reserve (n=47) components of the U.S. Armed Forces had at least 1 cold weather injury. The crude overall incidence rate of cold injury among all ACSM during the 2022-2023 cold season was 28.5 per 100,000 person-years (p-yrs), 15.2% lower than the rate observed during the 2021-2022 cold season (33.6 per 100,000 p-yrs). The rates of cold injuries varied among the Armed Forces, with the highest rates per 100,000 p-yrs observed in the Army, at 50.9, followed by the Marine Corps, at 32.2, the Air Force, at 18.9, the Navy, at 8.1, and the Coast Guard, at 5.1. Consistent with previous cold seasons, frostbite (54.0%) remained the most common type of cold injury among ACSM during the 2022-2023 cold season, while the proportions of hypothermia and immersion injuries were 16.5% and 30.3%, respectively. Cold injury rates among ACSM during the 2018 to 2023 cold seasons were generally highest for males, non-Hispanic Blacks, those under 20 years of age, and enlisted members. The number of cold injuries identified in service members deployed outside the U.S during the 2022-2023 cold season (n=10) was comparable to the 2 preceding cold seasons (11 in 2020-2021 and 12 in 2021-2022), with frostbite accounting for half (n=5) of the 2022-2023 cases.

Management of multiple frostbite casualties at a burn center: San Antonio, Texas, 12-20 February 2021.

BACKGROUND: Frostbite is an insidious disease that normally affects people of cold climates. Winter Storm Uri, which occurred from February 12-20, 2021, created unique metrological conditions for Texas. It caused prolonged sub-freezing temperatures and led to rolling blackouts, affecting 2.8 million Texans including 300,000 people in San Antonio. We report 13 frostbite patients admitted to one burn center during this event. OBJECTIVE: We aimed to determine the at-risk population for frostbite, to categorize their injury severity, and to describe their treatment. A secondary aim was to describe the rehabilitation management of these patients. METHODS: This is a single-center retrospective study. Each patient's injuries were assessed by a topographical grading system. Comparisons were made among those who were admitted to the intensive care unit (ICU), admitted to the progressive care unit (PCU), and treated as outpatients. RESULTS: Thirteen patients were identified. Ten (76.9 %) considered themselves homeless, and 9 (69.2 %) were directly exposed to the elements. The median delay between time of injury and presentation to a medical facility was 3 days (IQR 1-6). Only 3 patients presented to a medical facility within 24 h. Six (46 %) sustained grade 2 injuries, 2 (15 %) sustained grade 3 injuries, and 5 (38%) sustained grade 4 injuries. Only one patient met criteria to receive tissue plasminogen activator (tPA), which was discontinued due to hematochezia. Patients admitted to the ICU, when compared to patients admitted to the ward, had a longer length of stay (median 73 days v. 12 days, p = 0.0215), and required more amputations at below-the-knee or higher levels (3 v. 0, p-value 0.0442). CONCLUSION: In a region unaccustomed and perhaps unprepared to deal with winter storms, the population is particularly vulnerable to frostbite. Lack of awareness of frostbite injuries likely led to the delay in the presentation of patients, which prevented the timely use of tPA. Increasing public awareness may increase readiness.

Biopsychosocial factors associated with complications in patients with frostbite.

Cold weather injuries can be devastating and life changing. Biopsychosocial factors such as homelessness and mental illness (especially substance use disorders [SUDs]) are known risk factors for incurring frostbite. Based on clinical experience in an urban level 1 trauma center, we hypothesized that complications following frostbite injury would be influenced by homelessness, SUDs, and other forms of mental illness. The aim of this study was to examine the relationship between biopsychosocial factors and both amputations and unplanned hospital readmissions after cold injuries. Patients admitted with a diagnosis of frostbite between the winters of 2009 and 2018 were included in this retrospective cohort study. Descriptive statistics and multivariable regression assessed factors associated with outcomes of interest. Of the 148 patients in the study, 40 had unplanned readmissions within 1 year. Readmitted patients were significantly less likely to have a stable living situation (48.7% vs 75.0%, P = .005) and more likely to have an SUD (85.0% vs 60.2%, P = .005) or other psychiatric disorder (70.0% vs 50.9%, P = .042). Homelessness and SUDs were independent predictors of unplanned readmission. Overall, 18% of frostbite injuries resulted in amputation. Any history of drug and/or alcohol use independently predicted amputations. The study results suggest that additional hospital and community resources may need to be marshaled to prevent vulnerable patients with biopsychosocial risk factors from having complications after frostbite. Complications place a high downstream burden on healthcare systems. Clinicians caring for frostbite patients with comorbid conditions can use these findings to inform care and discharge decisions.

Review of our 10 years experience in cold burns at the burn center in the Southeast Anatolia region of Turkey.

BACKGROUND: Frostbite injuries remain to be one of the most complex and current problems of emergency medicine. Although cold burns are less frequent in hot climatic regions, it is a trauma, especially for men in our region. Also, most of the patients have difficulties in gaining early access to health and burn centers. METHODS: We performed a retrospective analysis on sixteen patients aged between 13 and 82, who were presented to Gazi Yasargil Training and Research Hospital Burn Center due to frostbite injuries. Data of each patient, including age, gender, injury time, extremity injuries, bacteriological observations, and general warming, were obtained from patients' files and computer records. RESULTS: After providing the first intervention to all the patients with trauma, a circulatory disorder of the injury area was deter-mined, and the treatment was provided accordingly. The treatment of these patients required very long and expensive operations, which often resulted in making them disabled. CONCLUSION: Deep frostbites in the cold winter months are frequently observed due to the unconscious use of ice and illegal crossings from the mountains at the Turkey border.

Socioeconomic and Comorbid Factors Associated With Frostbite Injury in the United States.

Frostbite largely affects the extremities and often results in long-term disability due to amputation. More regions are experiencing extremes in temperature which increases the risk of frostbite injury. The aim of this study was to detail social and comorbid factors associated with frostbite injury compared to isolated hand or foot burns. We used the National Inpatient Sample from 2016 to 2018 to identify admissions included in this study. Weighted incidence and multivariable analysis assessed characteristics and outcomes of frostbite and isolated hand or foot burn injury. In the United States, the estimated incidence of frostbite injury in those aged 15 and older was 0.95 per 100,000 persons and 4.44 per 100,000 persons with isolated hand and foot burns. Homelessness, mental health disorder, drug or alcohol abuse, and peripheral vascular disease were all associated with the risk of frostbite injury when compared to burn injury. We found that other insurance was associated with amputation following burn injury, while black race and homelessness were associated with amputation during a nonelective primary admission following frostbite injury. The differing risk factors associated with early amputation in frostbite and burn patients warrant a multicenter study including burn centers in North America.

Update: Cold Injuries, Active and Reserve Components, U.S. Armed Forces, July 2017­June 2022

From July 2021 through June 2022, a total of 482 members of the active (n=435) and reserve (n=47) components had at least 1 cold injury. The crude overall incidence rate of cold injury for all active component service members in 2021-2022 (33.1 per 100,000 person-years [p-yrs]) was slightly lower than the rate for the 2020-2021 cold season (35.5 per 100,000 p-yrs). In 2021-2022, frostbite was the most common type of cold injury among active component service members in all 4 services. Among active component members during the 2017-2022 cold seasons, overall rates of cold injuries were generally highest among male service members, non-Hispanic Black service members, the youngest (less than 20 years old), and those who were enlisted. The number of cold injuries associated with overseas deployments during the 2021-2022 cold season (n=13) was similar to the two previous cold seasons (10 in 2019-2020 and 11 in 2020-2021). Frostbite accounted for more than half (n=9) of the cold injuries identified in service members deployed outside of the U.S. during the 2021-2022 cold season.

Update: Cold weather injuries, active and reserve components, U.S. Armed Forces, July 2016-June 2021.

From July 2020 through June 2021, a total of 539 members of the active (n=469) and reserve (n=70) components had at least 1 medical encounter with a pri­mary diagnosis of cold injury. The crude overall incidence rate of cold injury for all active component service members in 2020­2021 (35.4 per 100,000 person-years [p-yrs]) was higher than the rate for the 2019­2020 cold season (27.5 per 100,000 p-yrs). In 2020­2021, frostbite was the most common type of cold injury among active component service members in all 4 services. Among active component members during the 2016­2021 cold seasons, overall rates of cold injuries were generally highest among male service members, non-Hispanic Black service members, the youngest (less than 20 years old), and those who were enlisted. The number of cold inju­ries associated with overseas deployments during the 2020­2021 cold season (n=10) was the lowest count during the 5-year surveillance period. Immersion foot accounted for half (n=5) of the cold weather injuries diagnosed and treated in service members deployed outside of the U.S. during the 2020­2021 cold season.

Cutaneous Cold Weather Injuries in the US Military.

Service members of the US Military are at risk for cutaneous cold weather injuries due to the demands of military training, combat operations, and peacekeeping missions. In this article, we review common cutaneous cold weather injuries likely to be encountered in the military, including frostbite, immersion foot, pernio, Raynaud phenomenon (RP), and cold urticaria. We aim to bring awareness to these specific injuries to improve diagnostic and treatment outcomes, both in service members and civilians.

Management of severe frostbite with iloprost, alteplase and heparin: a Yukon case series.

BACKGROUND: We identified the need to modernize frostbite management in our northern centre and implemented a treatment protocol in 2015. Our aim was to describe the clinical course of patients presenting to the hospital since the implementation of the protocol. METHODS: This was a retrospective case series from Whitehorse General Hospital, Whitehorse, Yukon Territory, Canada. We reviewed the charts of patients who presented to the hospital with grade 2-4 frostbite and were treated as per our protocol between Feb. 9, 2015, and Feb. 8, 2020. Patients with grade 2-4 frostbite received iloprost; in addition, those with grade 4 frostbite received alteplase and heparin. We determined the number of digits affected and salvaged, and the time from presentation to the emergency department to treatment initiation. We also examined patients' demographic characteristics, predisposing events, frostbite severity and adverse drug reactions. RESULTS: In 22 patients treated for grade 2-4 frostbite, 142 digits were affected: 59 with grade 2 frostbite, 25 with grade 3 frostbite and 58 with grade 4 frostbite; of the 142, 113 (79.6%) were salvaged. All 29 digits amputated had grade 4 frostbite. The mean time from presentation to iloprost initiation was reduced from 32.9 hours in 2015 to 3.0 hours in 2020. Sports (10 cases [45%]) and alcohol use (6 [27%]) were the most common precipitating events, with alcohol use tending to result in more severe injury (grade 4 in 5 of 6 cases). Adverse reactions with iloprost (e.g., headache) were common but mild. Adverse reactions with alteplase (e.g., bleeding) were less common but of greater clinical significance. INTERPRETATION: Over the study period, our protocol contributed to improvement in frostbite care at our institution, resulting in a digit salvage rate comparable to other published results. Our 5-year experience shows that advanced medical care of frostbite can be achieved, even at a rural centre.

Frostbite: Pathophysiology, Epidemiology, Diagnosis, Treatment, and Prevention.

Frostbite can occur during cold-weather operations when the temperature is <0°C (<32°F). When skin temperature is =-4°C (=25°F), ice crystals form in the blood, causing mechanical damage, inflammation, thrombosis, and cellular death. Lower temperatures, higher wind speeds, and moisture exacerbate the process. The frozen part or area should not be rewarmed unless the patient can remain in a warm environment; repeated freeze/thaw cycles cause further injury. Treatment involves rapid rewarming in a warm, circulating water bath 37°C to 39°C (99°F-102°F) or, if this is not possible, then contact with another human body. Thrombolytics show promise in the early treatment of frostbite. In the field, the depth and severity of the injury can be determined with laser Doppler ultrasound devices or thermography. In hospital settings, bone scintigraphy with single-photon emission computed tomography (SPECT) 2 to 4 days postinjury provides detailed information on the depth of the injury. Prevention is focused primarily on covering exposed skin with proper clothing and minimizing exposure to wind and moisture. The Generation III Extended Cold Weather Clothing System is an interchangeable 12-piece clothing ensemble designed for low temperatures and is compatible with other military systems. The Extreme Cold Vapor Barrier Boot has outer and inner layers composed of seamless rubber with wool insulation between, rated for low temperatures. The Generation 3 Modular Glove System consists of 11 different gloves and mitts with design features that assist in enhancing grip, aid in the use of mobile devices, and allow shooting firearms. Besides clothing, physical activity also increases body heat, reducing the risk of frostbite.

Update: Cold Weather Injuries, Active and Reserve Components, U.S. Armed Forces, July 2015-June 2020.

From July 2019 through June 2020, a total of 415 members of the active (n=363) and reserve (n=52) components had at least 1 medical encounter with a primary diagnosis of cold injury. The crude overall incidence rate of cold injury for all active component service members in 2019-2020 (27.4 per 100,000 person-years [p-yrs]) was lower than the rate for the 2018-2019 cold season (35.1 per 100,000 p-yrs) and was the lowest rate during the 5-year surveillance period. In 2019-2020, frostbite was the most common type of cold injury among active component service members in all 4 services. Among active component members during the 2015-2020 cold seasons, overall rates of cold injuries were generally highest among males, non-Hispanic black service members, the youngest (less than 20 years old), and those who were enlisted. The number of cold injuries associated with overseas deployments during the 2019-2020 cold season (n=10) was the lowest count during the 5-year surveillance period. Frostbite accounted for three-fifths (n=6; 60.0%) of the cold weather injuries diagnosed and treated in service members deployed outside of the U.S during the 2019-2020 cold season.

Amputation Risk Factors in Severely Frostbitten Patients.

In recent years, the incidence of frostbite has increased among healthy young adults who practice winter sports (skiing, mountaineering, ice climbing and technical climbing/alpinism) at both the professional and amateur levels. Moreover, given that the population most frequently affected is healthy and active, frostbite supposes a substantial interruption of their normal activity and in most cases is associated with long-term sequelae. It particularly has a higher impact when the affected person's daily activities require exposure to cold environments, as either sports practices or work activities in which low temperatures are a constant (ski patrols, mountain guides, avalanche forecasters, workers in the cold chain, etc.). Clinical experience with humans shows a limited reversibility of injuries via potential tissue regeneration, which can be fostered with optimal medical management. Data were collected from 92 frostbitten patients in order to evaluate factors that represent a risk of amputation after severe frostbite. Mountain range, years of expertise in winter mountaineering, time elapsed before rewarming and especially altitude were the most important factors for a poor prognosis.

Update: Cold weather injuries, active and reserve components, U.S. Armed Forces, July 2013-June 2018.

From July 2017 through June 2018, a total of 478 members of the active (n=402) and reserve (n=76) components had at least one medical encounter with a primary diagnosis of cold injury. The crude overall incidence rate of cold injury for all active component service members in 2017-2018 was 19.6% higher than the rate for the 2016-2017 cold season and was the highest rate since the 2013-2014 season. Frostbite was the most common type of cold injury among active component service members in 2017-2018. Among active component members during the 2013-2018 cold seasons, overall rates of cold injuries were generally highest among males, non-Hispanic black service members, the youngest (less than 20 years old), and those who were enlisted. As noted in prior MSMR updates, the rate of all cold injuries among active component Army members was considerably higher in females than in males due to a much higher rate of frostbite among female soldiers. The numbers of cold injuries associated with overseas deployments have fallen precipitously in the past three cold seasons and included 17 cases in the most recent year.

Frostbite in the Norwegian Armed Forces. / Frostskader i Forsvaret.

BAKGRUNN: Det finnes lite forskning på forekomst av frostskader, både sivilt og militært. Prognosen og tidsforløpet ved slike skader har ikke tidligere vært undersøkt i større kohorter. MATERIALE OG METODE: Deltagerne var personer registrert i Forsvarets helseregister med kulde- og frostskade i tidsrommet 1.1.2010-31.12.2014. Data om diagnostikk, forløp og behandling ble innhentet fra i alt 460 personer ved hjelp av et spørreskjema. Svarprosenten på undersøkelsen var 66. RESULTATER: 397 av 460 personer (86,3 %) som var registrert med frostskade i Forsvarets helseregister bekreftet at de hadde hatt en kulde- og frostskade. 123 av 397 personene som svarte (30,1 %) anga at de hadde hatt blemmer, noe som gir mistanke om at de hadde pådratt seg annengrads frostskade. 225 av 397 (56,7 %) anga at de hadde hatt frostskade, men ikke blemmer. De aller fleste fikk frostskaden under feltøvelse/vinterøvelse (81,1 %), og ⅔ av de som pådro seg skader var vernepliktige. Langt de fleste hadde skader på fingre/hender eller tær/føtter (96,0 %). To av tre (69,8 %) hadde fortsatt plager fra sin frostskade mer enn to år etter skadetidspunktet. FORTOLKNING: Mange i militæret pådrar seg frostskader under tjenestegjøring. En femdel anga kroniske helseplager som påvirker arbeidsevnen. Kunnskap om forekomsten av frostskader hos militært mannskap er viktig for Forsvarets videre skadeforebyggende arbeid.

Frostbite Injuries in the Austrian Alps: A Retrospective 11-Year National Registry Study.

OBJECTIVES: Frostbite is a cold injury mostly affecting the extremities. The objective of this study was to reveal the incidence of frostbite injuries in the Austrian Alps, to search for frostbite risk factors, and thereby optimize prevention and treatment. METHODS: Out-of-hospital data in the National Registry of Alpine Accidents from January 1, 2005, to December 31, 2015, were screened for frostbite injuries. Cases in the registry were merged with clinical data from the major trauma center in western Austria, Innsbruck Medical University Hospital, and statistically analyzed. RESULTS: Documented in the National Registry are 114,595 injured persons in the 11-year study period. Thirty-one frostbite cases were documented nationwide, 18 (58%) of which occurred in the western states of Austria and were therefore potentially referred to the Innsbruck Medical University Hospital. Six (19.6%) patients were female. Frostbite was almost exclusively related to fingers and toes (90% of cases). CONCLUSIONS: Frostbite injuries in the Austrian Alps are rare. With an incidence of 0.07/100,000, three to four clinically relevant frostbite injuries occur annually. Men are at greater risk for frostbite injuries than women. Fingers and toes are at greatest risk. Proper preparation of outdoor activities and cold-protective gear can help prevent frostbite injuries.

Pediatric frostbite: A 10-year single-center retrospective study.

OBJECTIVE: To describe frostbite (freezing cold injured tissue) in children and intrinsic (psychological and behavioral) and extrinsic (meteorological and safety hazard) factors related to the injury. METHODS: Retrospective chart review of children <18 years old referred to a regional pediatric hospital for frostbite, to determine the demographics, environment, and risk factors related to injuries. RESULTS: 47 patients met the inclusion criteria. Median age was 15 years (IQR 12-16). All injuries occurred between November and March. 49% were admitted to the hospital and frostbite was associated with use of alcohol (53%), cigarettes (34%), marijuana (23%), and symptoms of depression (with and without suicidal ideation) (32%). Frostbite injury treated with conservative wound management presented at <-6°C and injury that underwent surgical procedures occurred at temperatures ≤-23°C (p=0.001). Longer exposure duration also significantly increased the likelihood of a surgical procedure (p<0.001). Intoxication and lack of supervision were two common factors, with lack of supervision at time of injury most common among patients 0-12 years (64%), and intoxication most common among patients ages 13-17 (61%). CONCLUSION: Frostbite injuries in children begins at temperatures <-6°C; with risk of tissue loss increasing at temperatures below -23°C. Lack of supervision and intoxication are major risk factors for frostbite in children. Two-thirds of younger children were unsupervised, whereas intoxication was frequently related to frostbite in adolescents. Both of these factors can be addressed through an education-based prevention program.

Frostbite in the United States: An Examination of the National Burn Repository and National Trauma Data Bank.

Frostbite is a form of thermal injury that can have devastating consequences for patients, including digit amputations and sometimes more proximal amputations. To the best of the authors' knowledge, no one has determined national characteristics of frostbite patients, nor the prevalence of these diagnostic and therapeutic modalities. This is the first look at nationwide trends in the treatment of frostbite in the United States. Patients with frostbite injury were identified in the National Trauma Data Bank (NTDB) and National Burn Repository (NBR). Inclusion criteria were diagnosis codes of frostbite injury. The number of frostbite patients treated each year is relatively stable at NBR (N = 497) contributing centers. The NTDB (N = 388) has shown a trend toward increased numbers of frostbite patients. Both databases show an overwhelmingly male demographic (NBR 81.1%, NTDB 75.8%) with a predominance of lower extremity injury (NBR 47.9%, NTDB 66%). Hospital days were similar in both databases (NBR 10.7, NTDB 9.5). Both databases show that frostbite patients frequently require an intensive care unit (ICU) stay, with an average of 8.5 ICU days for NBR patients and 5.9 days for NTDB patients. Frostbite is often a severe disease process that results in relatively long hospital and ICU stays, as well as frequent significant surgeries including amputation. Often, patients afflicted with frostbite require discharge to skilled care before returning home. As more centers encounter patients with frostbite injury, the need for increased awareness of limb/digit saving treatment modalities should be addressed through education from national associations.

Medical Encounters During a Joint Canadian/U.S. Exercise in the High Arctic (Exercise Arctic Ram).

The Arctic Ram Exercise was conducted in February 2016, near Resolute Bay on Cornwallis Island in Nunavut, Canada, to demonstrate the ability of the Canadian Armed Forces (CAF) to rapidly deploy to the arctic as an immediate response team. This report describes medical problems experienced by the 187 CAF and 28 U.S. forces involved in the exercise. Sixty-six airborne soldiers performed tactical static line jumps and linked up with soldiers on the ground for the exercise. Medical events were recorded by medics on the drop zone and by medical personnel at the Unit Medical Station in Resolute Bay. Average temperature during the exercise was -21°C and wind chill was -44°C. Two U.S. soldiers were injured in association with the jump and an additional 62 patients presented at the clinic during the exercise for an overall medical event incidence of 30%. The incidence of frostbite was 17%. At the end of the exercise, a physician actively examined CAF soldiers in one unit (n = 126) and found that 21% had experienced frostbite. The incidence of frostbite was high in this exercise compared to past cold-weather military operations, likely related to the very low temperatures and wind chills.

Amputations in the burn unit: A retrospective analysis of 82 patients across 12 years.

BACKGROUND: The aim of this study is to analyze the data of amputees in the burn center of the Inner Mongolia region and to provide instructive suggestions for a preventative reduction of the amputation rate. METHODS: Between 2004 and 2016, all patient medical profiles were reviewed to extract data of patients with major amputation. Demographic data, mechanism of injury, location and level of amputation were recorded. The healing condition of the residual limb was noted. In addition, we performed comparisons of amputees whose injuries were caused by electricity and those whose injuries were related to other mechanisms. RESULTS: Among the 82 amputees in our study, about 89% of amputees were male patients and the predominant age-group was 20-29 years (26.8%). The injuries occurred most commonly at the work place (62.2%) with laborers (40.2%) being the most commonly affected. The most common mechanisms of injury were electricity (51.2%) and hot crush (14.6%), followed by frostbite (13.4%). The most common level of amputation was the right wrist joint (n=16). About 60.4% of the amputation sites were by primary healing. The rate of escharotomy in electrical burn amputees (n=27, 62.3%) was significantly higher than the other groups (n=16, 40.0%, p<0.05). The first amputation in electrical burn group (7.2±5.6) was significantly earlier than the other etiology group (17.9±13.7, p<0.05). CONCLUSIONS: Electrical burns were the major mechanism of injury among amputees. Effective safety measures, factory modifications, and adequate instructions should be implemented to protect laborers. Urgent interdisciplinary communication should be taken into account for the prevention reduction of the amputation rate in our region.

Neurovascular hand symptoms in relation to cold exposure in northern Sweden: a population-based study.

PURPOSE: To describe the self-reported ambient cold exposure in northern Sweden and to relate the level of cumulative cold exposure to the occurrence of sensory and vascular hand symptoms. We hypothesize that cold exposure is positively related to reporting such symptoms. METHODS: A questionnaire about cold exposure and related symptoms was sent out to 35,144 subjects aged 18-70 years and living in northern Sweden. RESULTS: A total of 12,627 out of 35,144 subjects returned the questionnaire (response rate 35.9%). Subjects living in the rural alpine areas reported more extensive cold exposure both during work and leisure time compared to the urbanized coastal regions. Frostbite in the hands was present in 11.4% of men and 7.1% of women, cold sensitivity was present in 9.7 and 14.4%, and Raynaud's phenomenon was present in 11.0% of men and 14.0% of women. There was a positive association between cumulative cold exposure and neurovascular hand symptoms. CONCLUSION: The present study demonstrates that the cold environment in northern Sweden might be an underestimated health risk. Our hypothesis that cold exposure is positively related to reporting of neurovascular hand symptoms was supported by our findings. In addition, such symptoms were common not only in conjunction with an overt cold injury. Our results warrant further study on pathophysiological mechanisms and suggest the need for confirmatory prevalence studies to support national public health planning.