Traumatic brain injury alters the effects of class II invariant peptide (CLIP) antagonism on chronic meningeal CLIP + B cells, neuropathology, and neurobehavioral impairment in 5xFAD mice.

BACKGROUND: Traumatic brain injury (TBI) is a significant risk factor for Alzheimer's disease (AD), and accumulating evidence supports a role for adaptive immune B and T cells in both TBI and AD pathogenesis. We previously identified B cell and major histocompatibility complex class II (MHCII)-associated invariant chain peptide (CLIP)-positive B cell expansion after TBI. We also showed that antagonizing CLIP binding to the antigen presenting groove of MHCII after TBI acutely reduced CLIP + splenic B cells and was neuroprotective. The current study investigated the chronic effects of antagonizing CLIP in the 5xFAD Alzheimer's mouse model, with and without TBI. METHODS: 12-week-old male wild type (WT) and 5xFAD mice were administered either CLIP antagonist peptide (CAP) or vehicle, once at 30 min after either sham or a lateral fluid percussion injury (FPI). Analyses included flow cytometric analysis of immune cells in dural meninges and spleen, histopathological analysis of the brain, magnetic resonance diffusion tensor imaging, cerebrovascular analysis, and assessment of motor and neurobehavioral function over the ensuing 6 months. RESULTS: 9-month-old 5xFAD mice had significantly more CLIP + B cells in the meninges compared to age-matched WT mice. A one-time treatment with CAP significantly reduced this population in 5xFAD mice. Importantly, CAP also improved some of the immune, histopathological, and neurobehavioral impairments in 5xFAD mice over the ensuing six months. Although FPI did not further elevate meningeal CLIP + B cells, it did negate the ability of CAP to reduce meningeal CLIP + B cells in the 5xFAD mice. FPI at 3 months of age exacerbated some aspects of AD pathology in 5xFAD mice, including further reducing hippocampal neurogenesis, increasing plaque deposition in CA3, altering microgliosis, and disrupting the cerebrovascular structure. CAP treatment after injury ameliorated some but not all of these FPI effects.

Cognitive integrity in Non-Demented Individuals with Alzheimer's Neuropathology is associated with preservation and remodeling of dendritic spines.

INTRODUCTION: Individuals referred to as Non-Demented with Alzheimer's Neuropathology (NDAN) exhibit cognitive resilience despite presenting Alzheimer's disease (AD) histopathological signs. Investigating the mechanisms behind this resilience may unveil crucial insights into AD resistance. METHODS: DiI labeling technique was used to analyze dendritic spine morphology in control (CTRL), AD, and NDAN post mortem frontal cortex, particularly focusing on spine types near and far from amyloid beta (Aß) plaques. RESULTS: NDAN subjects displayed a higher spine density in regions distant from Aß plaques versus AD patients. In distal areas from the plaques, NDAN individuals exhibited more immature spines, while AD patients had a prevalence of mature spines. Additionally, our examination of levels of Peptidyl-prolyl cis-trans isomerase NIMA-interacting 1 (Pin1), a protein associated with synaptic plasticity and AD, showed significantly lower expression in AD versus NDAN and CTRL. DISCUSSION: These results suggest that NDAN individuals undergo synaptic remodeling, potentially facilitated by Pin1, serving as a compensatory mechanism to preserve cognitive function despite AD pathology. HIGHLIGHTS: Spine density is reduced near Aß plaques compared to the distal area in CTRL, AD, and NDAN dendrites. NDAN shows higher spine density than AD in areas far from Aß plaques. Far from Aß plaques, NDAN has a higher density of immature spines, AD a higher density of mature spines. AD individuals show significantly lower levels of Pin1 compared to NDAN and CTRL.

Effectiveness of Concurrent Ankle Arthroscopy During Open Reduction and Internal Fixation of Malleolar Fractures in Prevention of Common Short-Term Complications.

Rotational malleolar fractures result in a high prevalence of intra-articular pathologies; therefore, routine arthroscopic assessment may be beneficial in the surgical treatment of ankle fractures. However, the clinical studies regarding the effectiveness of arthroscopy thus far have mixed results. We investigated the efficacy of concurrent arthroscopy during the treatment of malleolar fractures using a large U.S. healthcare data set. Those who had arthroscopy were compared with those who did not, during the surgical treatment of malleolar fractures, while adjusting for covariates of clinical relevance. The analysis showed that concurrent arthroscopy is protective against postoperative repeat surgery (OR = 0.13, 95CI = 0.02-0.41) and wound dehiscence (OR = 0.18, 95CI = 0.03-0.56). The number of added arthroscopy cases needed to avoid one repeat surgery was 74, while that of wound dehiscence was 52. Further studies are needed to determine if routine use of arthroscopy is justifiable in the surgical treatment of malleolar fractures, given the additional costs and time to the healthcare system.

Trajectories of Diabetes-Related Sequelae for Identifying Transition Probabilities, and Optimal Timepoints for Prevention of Ulceration, Infection, and Amputation.

To reduce diabetes-related complications and to avoid futile procedures, foot and ankle surgeons need to understand the relative timings of catastrophic events, their incidence, and probabilities of transitions between disease states in diabetes in different patient populations. For this study, we tracked medical events (including an initial diagnosis of diabetes, ulcer, wound care, osteomyelitis, amputation, and reamputation, in order of severity) and the time between each such event in patients with diabetes, stratifying by sex, race, and ethnicity. We found that the longest average duration between the different lower extremity states was a diagnosis of diabetes to the occurrence of ulcer at 1137 days (38 months). The average durations of amputation to reamputation, osteomyelitis, wound care, and ulcer were 18, 49, 23, and 18 days, respectively. The length of each disease transition for females was greater, while those of the Hispanic population were shorter than in the total cohort. This knowledge may permit surgeons to time and tailor treatments to their patients, and help patients to address, delay, or avoid complications.

The Effect of Limb Salvage Efforts in Different Age Groups: Relationships Between Major and Minor Amputations.

"Limb salvage" efforts, such as performing minor amputations before infections spread proximally from the foot to decrease major lower extremity amputation, are an important part of healthcare today. It is unclear whether these efforts are preventing the number of major amputations and improving patients' quality of life and the cost-effectiveness of the U.S. healthcare system. Rates of non-traumatic lower extremity amputation (NLEA) among patients with diabetes decreased in the early 2000s but rebounded in the 2010s. We analyzed the proportion of major amputations and differences in amputation rates between age groups in Texas. Patient data was extracted from the Texas Hospital Discharge Data Public Use Data File. Population estimates were obtained from the Texas Population Estimates Program from 2011 to 2015 and from intercensal estimates provided by the U.S. Census Bureau from 2006 to 2010. Raw numbers of minor, major, and all NLEA surgeries and the ratio of major amputations to total amputations per year were reported for each age group. Poisson regression and Joinpoint analyses were performed to capture these changes in trends. Rates of amputations increased, with significant decreasing relative prevalence of major amputations. Patients aged 45 to 64 with diabetes are likely driving these increases. Rates of lower extremity amputation in patients with diabetes increased from 2009 to 2015. This holds for all and minor amputations. In contrast, the ratio of major to all amputations decreased from 2010. Utilization of major and minor amputation differs between age groups, remaining stable in the youngest subjects, with minor amputation rates increasing in those aged 45 to 64.

Safe driving recommendations following lower extremity orthopedic surgery: a systematic review.

PURPOSE: We analyzed the published literature on return-to-driving (RTD) recommendations following lower extremity orthopedic surgery, including knee and hip arthroplasty and ankle and foot surgery. METHODS: We conducted a PubMed MEDLINE database search for the relevant literature spanning from 1988 to 2022. Data were extracted from the selected articles independently by six investigators, and the mean, standard deviation, and range of RTD recommendations for each surgical region and procedure were calculated. RESULTS: The 34 studies included in our review evaluated brake response time, reaction time, movement time, braking force, and other parameters. Average RTD recommendations in weeks were: hip surgeries, 4.1 (± 2.7); foot surgeries, 6.67 (± 0.94); Achilles surgeries, 6.67 (± 0.25); ankle surgeries, 4 (± 2); knee surgeries, 5.42 (± 0.77); and multiple lower extremity surgeries, 3.85 (± 0.15). CONCLUSION: Our findings can assist physicians in providing informed recommendations to patients, promoting safe driving practices, and optimizing postoperative recovery. LEVEL OF EVIDENCE: Therapeutic, Level III: Retrospective comparative study.

Development and Evaluation of Rehabilitation Service Areas for the United States.

BACKGROUND: Geographic areas have been developed for many healthcare sectors including acute and primary care. These areas aid in understanding health care supply, use, and outcomes. However, little attention has been given to developing similar geographic tools for understanding rehabilitation in post-acute care. The purpose of this study was to develop and characterize post-acute care Rehabilitation Service Areas (RSAs) in the United States (US) that reflect rehabilitation use by Medicare beneficiaries. METHODS: A patient origin study was conducted to cluster beneficiary ZIP (Zone Improvement Plan) code tabulation areas (ZCTAs) with providers who service those areas using Ward's clustering method. We used US national Medicare claims data for 2013 to 2015 for beneficiaries discharged from an acute care hospital to an inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term care hospital (LTCH), or home health agency (HHA). Medicare is a US health insurance program primarily for older adults. The study population included patient records across all diagnostic groups. We used IRF, SNF, LTCH and HHA services to create the RSAs. We used 2013 and 2014 data (n = 2,730,366) to develop the RSAs and 2015 data (n = 1,118,936) to evaluate stability. We described the RSAs by provider type availability, population, and traveling patterns among beneficiaries. RESULTS: The method resulted in 1,711 discrete RSAs. 38.7% of these RSAs had IRFs, 16.1% had LTCHs, and 99.7% had SNFs. The number of RSAs varied across states; some had fewer than 10 while others had greater than 70. Overall, 21.9% of beneficiaries traveled from the RSA where they resided to another RSA for care. CONCLUSIONS: Rehabilitation Service Areas are a new tool for the measurement and understanding of post-acute care utilization, resources, quality, and outcomes. These areas provide policy makers, researchers, and administrators with small-area boundaries to assess access, supply, demand, and understanding of financing to improve practice and policy for post-acute care in the US.

Preserved autophagy in cognitively intact non-demented individuals with Alzheimer's neuropathology.

INTRODUCTION: Growing evidence supports that dysfunctional autophagy, the major cell mechanism responsible for removing protein aggregates and a route of clearance for Tau in healthy neurons, is a major finding in demented Alzheimer's disease (AD) patients. However, the association of autophagy with maintenance of cognitive integrity in resilient individuals who have AD neuropathology but remain non-demented (NDAN) has not been evaluated. METHODS: Using post mortem brain samples from age-matched healthy control, AD, and NDAN subjects, we evaluated autophagy in relation to Tau pathology using Western blot, immunofluorescence and RNA-seq. RESULTS: Compared to AD patients, NDAN subjects had preserved autophagy and reduced tauopathy. Furthermore, expression of autophagy genes and AD-related proteins were significantly associated in NDAN compared to AD and control subjects. DISCUSSION: Our results suggest preserved autophagy is a protective mechanism that maintains cognitive integrity in NDAN individuals. This novel observation supports the potential of autophagy-inducing strategies in AD therapeutics. HIGHLIGHTS: NDAN subjects have preserved autophagic protein levels comparable with control subjects. Compared to control subjects, NDAN subjects have significantly reduced Tau oligomers and PHF Tau phosphorylation at synapses that negatively correlate with autophagy markers. Transcription of autophagy genes strongly associates with AD-related proteins in NDAN donors.

Preoperative Serum Albumin and Other Risk Factors Related to 30-Day Postoperative Complications in Total Ankle Arthroplasty.

This study investigates effects of preoperative albumin on 30-day total ankle arthroplasty (TAA) outcomes. Additionally, other preoperative risk factors are addressed, including American Anesthesia Society (ASA) class, functional status, chronic obstructive pulmonary disease (COPD), diabetes, smoking status, time of operation, and age. Outcomes assessed were readmission, return to operating room, surgical site infection, wound dehiscence, and total length of stay (TLOS). Data were extracted from the National Surgical Quality Improvement Program database. Bivariate comparisons were analyzed using correlation coefficients, t tests, or chi-squared tests; multivariate comparisons used linear or logistic regression. Our data showed no significant correlation between serum albumin and patients with readmission (odds ratio -0.14, P = 0.06), return to operating room (-0.07, P = 0.61), or surgical site infection (-0.08, P = 0.56). With bivariate analysis, functional status and COPD were significant for readmission (12.67, P < 0.001 and 7.83, P < 0.001, respectively) and dehiscence (30.52, P < 0.001 and 6.74, P = 0.05, respectively), while high ASA class (0.4, P = 0.01), increased age (0.1, P < 0.001), and longer time of operation (0.19, P < 0.001) were associated with longer TLOS. With multivariate analysis, functional status showed higher odds of readmission (7.42, P = 0.02) and dehiscence (20.47, P = 0.01), while COPD showed higher odds for readmission (6.65, P < 0.001) and longer TLOS (0.31, P = 0.05). High ASA class (0.42, P < 0.001) and female sex (0.32, P < 0.001) also had higher odds for longer TLOS. In summary, low albumin was not significant for readmission, return to operating room, or surgical site infection in TAA. COPD, functional status, high ASA class, longer time of operation, increased age, and female sex were all correlated with adverse outcomes in TAA.

CVP and echo Measurements are Associated with Improved Outcomes in Patients with Gastrointestinal (GI) Hemorrhage: A Retrospective Analysis of the MIMIC- IV Database.

Purpose: Mortality associated with acute Gastrointestinal (GI) hemorrhage in intensive care units (ICU) has remained high in patients suffering from hemodynamic instability. Prompt recognition and rapid assessment of bleeding severity are crucial to improve survival. Central venous pressure (CVP) monitoring is commonly used for early recognition of intravascular imbalances, but its effectiveness in predicting fluid responsiveness is often questioned. Echocardiography (echo) is a rapid, noninvasive method to repeatedly assess cardiac function and fluid responsiveness. This study investigated the impact of CVP and echo measurements on the outcomes of critically ill patients with GI hemorrhage. Methods: The study was based on the Medical Information Mart for Intensive Care IV (MIMIC- IV) database. Patients were divided into four groups according to the usage of CVP and/or echo. The primary outcomes were 7-day, 14-day, 28-day, and overall mortalities after ICU admission. Cox Proportional-Hazards Models were used to elucidate the relationship between CVP/ Echo monitoring and mortality. The severity of illness of patients were adjusted by qSOFA score, SOFA score and base deficit level at admission. Results: Among 1705 eligible patients, 82 patients had both CVP and echo, 85 had CVP only, and 116 had Echo only. The results of survival analysis indicated that, comparing with those without either CVP or echo, the echo utilization was associated with improved mortalities at all time points during ICU stay for patients with moderate GI hemorrhage, and the combined use of CVP and echo was associated with lower 7-day,14-day and overall mortalities for patients with severe GI hemorrhage. Conclusion: Early usage of CVP and echo monitoring or echo alone are associated with lower mortality in the short and long-term when compared to patients without either measurement. Clinicians should consider goal-directed resuscitation guided by echo with/without CVP in patients with GI hemorrhage early after admission to ICU.

Disparities in esophageal cancer care based on race: a National Cancer Database analysis.

Esophageal cancer is one of the most common cancer killers in our country. The effects of racial disparities on care for esophageal cancer patients are incompletely understood. Using the National Cancer Database, we investigated racial disparities in treatment and outcome of esophageal cancer patients. The National Cancer Database was queried from 2004 to 2017. Logistic regression and survival analysis were used to determine racial differences in access, treatment and outcome. A total of 127,098 patients were included. All minority groups were more likely to be diagnosed at advanced stages versus Caucasians after adjusting for covariates (African American OR-1.64 [95% confidence interval 1.53-1.76], Hispanic OR-1.19 [1.08-1.32], Asian OR-1.78 [1.55-2.06]). After adjustment, all minorities were less likely at every stage to receive surgery. Despite these disparities, Hispanics and Asians had improved survival compared with Caucasians. African Americans had worse survival. Racial disparities for receiving surgery were present in both academic and community institutions, and at high-volume and low-volume institutions. Surgery partially mediated the survival difference between African Americans and Caucasians (HR-1.13 [1.10-1.16] and HR-1.04 [1.02-1.07], without and with adjustment of surgery).There are racial disparities in the treatment of esophageal cancer. Despite these disparities, Hispanics and Asians have improved overall survival versus Caucasians. African Americans have the worst overall survival. Racial disparities likely affect outcome in esophageal cancer. But other factors, such as epigenetics and tumor biology, may correlate more strongly with outcome for patients with esophageal cancer.

Digital Biomarkers of Gait and Balance in Diabetic Foot, Measurable by Wearable Inertial Measurement Units: A Mini Review.

People with diabetic foot frequently exhibit gait and balance dysfunction. Recent advances in wearable inertial measurement units (IMUs) enable to assess some of the gait and balance dysfunction associated with diabetic foot (i.e., digital biomarkers of gait and balance). However, there is no review to inform digital biomarkers of gait and balance dysfunction related to diabetic foot, measurable by wearable IMUs (e.g., what gait and balance parameters can wearable IMUs collect? Are the measurements repeatable?). Accordingly, we conducted a web-based, mini review using PubMed. Our search was limited to human subjects and English-written papers published in peer-reviewed journals. We identified 20 papers in this mini review. We found preliminary evidence of digital biomarkers of gait and balance dysfunction in people with diabetic foot, such as slow gait speed, large gait variability, unstable gait initiation, and large body sway. However, due to heterogeneities in included papers in terms of study design, movement tasks, and small sample size, more studies are recommended to confirm this preliminary evidence. Additionally, based on our mini review, we recommend establishing appropriate strategies to successfully incorporate wearable-based assessment into clinical practice for diabetic foot care.

An Updated Epidemiology of Foot and Ankle Fractures in the United States: Complications, Mechanisms, and Risk Factors.

Foot and ankle fractures are prevalent emergent injuries, about which there remains a lack of in-depth epidemiological information. This analysis of the epidemiology of foot and ankle injuries in the United States updates a previously conducted study. Data from the National Trauma Data Bank (2012-2017) were used for analysis. Demographic variables, mechanism of injuries, and comorbidities were analyzed to determine risk factors for complications after foot and ankle injuries. Young adults aged 21 to 30 years had the highest injury rates; however, in general, older individuals were more at risk for complications. Black individuals were more at risk for certain complications, while Asians were at lower risk, when compared to White individuals. The comorbidities of bleeding disorders, diabetes, smoking, hypertension, and chronic obstructive pulmonary disease all increased risk of at least 1 complication. In terms of mechanism, traffic incidents were found to be the most strongly associated with complications.

Diabetes-Specific Dementia: A Structured Literature Review of Cognitive Assessment Methods.

Diabetes mellitus is a known risk factor for the development of multiple subtypes of dementia and mild cognitive impairment. Recent research identifies a cause-specific diabetes-related dementia with a unique set of characteristics. Currently, there is no standard cognitive assessment battery recommended to specifically assess dementia that is a direct consequence of chronic diabetes, and some evaluations have been used for decades with minimal revisions, regardless of appropriateness. We performed a systematic review of the dementia/cognition evaluation methods most commonly used in the literature for assessing diabetic patients and identified which cognitive domains are typically assessed in this setting, and whether cognitive changes were more reflective of a vascular pathology, Alzheimer's pathology, or something else entirely. Search results yielded 1089 articles. After screening for appropriateness, a total of 11 full-text articles were assessed. In general, subjects in the reviewed studies were assessed using a variety of testing methods, examining different combinations of cognitive domains. A standard, clear definition of which cognitive domains are the most important to assess in diabetic patients is needed in order to determine what combination of assessment tools are most pertinent. Given the growing subset of the US population, careful reconsideration of cognitive assessment methods is needed to create self-care plans that take into account a specific collection of cognitive challenges for those with diabetes.

Delayed Diagnosis of Charcot Foot: A Systematic Review.

This study aims to examine the duration and rate of delayed diagnosis in Charcot foot. We systematically reviewed articles published in Medline, SCOPUS, and Cumulative Index of Nursing and Allied Health Literature to identify articles discussing delayed or misdiagnosis of Charcot foot. Random-effects models were generated to determine the average time from symptom onset to correct diagnosis (diagnostic delay duration) and proportion of patients misdiagnosed prior to being correctly diagnosed (delayed diagnosis rate). Our search identified 142 articles, 7 of which are included in this review. The review found that 53.2% of cases of Charcot osteoarthropathy experienced a delay in diagnosis (95% CI: 28.9%-77.4%). Overall, the duration of diagnostic delay was determined to be 86.9 days (95% CI: 10.5-162.1). We found that patients with Charcot foot experienced prolonged delays from symptom onset to correct diagnosis, and a majority of patients are misdiagnosed. These delays in diagnosis contribute to worse patient outcomes.

How to Identify Team-based Primary Care in the United States Using Medicare Data.

BACKGROUND: Studying team-based primary care using 100% national outpatient Medicare data is not feasible, due to limitations in the availability of this dataset to researchers. METHODS: We assessed whether analyses using different sets of Medicare data can produce results similar to those from analyses using 100% data from an entire state, in identifying primary care teams through social network analysis. First, we used data from 100% Medicare beneficiaries, restricted to those within a primary care services area (PCSA), to identify primary care teams. Second, we used data from a 20% sample of Medicare beneficiaries and defined shared care by 2 providers using 2 different cutoffs for the minimum required number of shared patients, to identify primary care teams. RESULTS: The team practices identified with social network analysis using the 20% sample and a cutoff of 6 patients shared between 2 primary care providers had good agreement with team practices identified using statewide data (F measure: 90.9%). Use of 100% data within a small area geographic boundary, such as PCSAs, had an F measure of 83.4%. The percent of practices identified from these datasets that coincided with practices identified from statewide data were 86% versus 100%, respectively. CONCLUSIONS: Depending on specific study purposes, researchers could use either 100% data from Medicare beneficiaries in randomly selected PCSAs, or data from a 20% national sample of Medicare beneficiaries to study team-based primary care in the United States.

Geographical Variation in Traumatic Brain Injury Mortality by Proximity to the Nearest Neurosurgeon.

BACKGROUND: Trauma mortality disproportionately affects populations farther from potentially lifesaving trauma care, and traumatic brain injury (TBI) is no exception. Previous examinations have examined proximity to trauma centers as an explanation for trauma mortality, but little is known about the relationship between proximity to neurosurgeons specifically in TBI mortality. MATERIALS AND METHODS: In this cross-sectional study, county-level TBI mortality rates from 2008 to 2014 were examined in relation to the distance to the nearest neurosurgeon and trauma facility. The locations of practicing neurosurgeons and trauma facilities in the United States were determined by geocoding data from the 2017 Medicare Physician and Other Supplier and Provider of Services files (respectively). The association between TBI mortality and the distance from the population-weighted centroid of the county to a closest neurosurgeon and trauma facility was examined using multivariate negative binomial regression. RESULTS: A total of 761 of the 3108 counties (24.5%) in the continental United States were excluded from the analysis because they had 20 or fewer TBI deaths during this time, producing unstable estimates. Excluded counties accounted for 1.67% of the US population. Multivariate analysis revealed a county's mortality increased 10% for every 25 miles from the nearest neurosurgeon (adjusted incident rate ratio: 1.10 [95% confidence interval: 1.08-1.12]; P < 0.001). The distance to the nearest trauma facility was not found to be significantly associated with mortality (adjusted incident rate ratio: 1.01 [95% confidence interval: 0.99-1.03]; P = 0.36). CONCLUSIONS: These findings suggest that proximity to neurosurgeons may influence county-level TBI mortality. Further research into this topic with more granular data may help to allocate scarce public health resources.

Post-acute care use patterns among Hospital Service Areas by older adults in the United States: a cross-sectional study.

BACKGROUND: Despite the success of stroke rehabilitation services, differences in service utilization exist. Some patients with stroke may travel across regions to receive necessary care prescribed by their physician. It is unknown how availability and combinations of post-acute care facilities in local healthcare markets influence use patterns. We present the distribution of skilled nursing, inpatient rehabilitation, and long-term care hospital services across Hospital Service Areas among a national stroke cohort, and we describe drivers of post-acute care service use. METHODS: We extracted data from 2013 to 2014 of a national stroke cohort using Medicare beneficiaries (174,498 total records across 3232 Hospital Service Areas). Patients' ZIP code of residence was linked to the facility ZIP code where care was received. If the patient did not live in the Hospital Service Area where they received care, they were considered a "traveler". We performed multivariable logistic regression to regress traveling status on the care combinations available where the patient lived. RESULTS: Although 73.4% of all Hospital Service Areas were skilled nursing-only, only 23.5% of all patients received care in skilled nursing-only Hospital Service Areas; 40.8% of all patients received care in Hospital Service Areas with only inpatient rehabilitation and skilled nursing, which represented only 18.2% of all Hospital Service Areas. Thirty-five percent of patients traveled to a different Hospital Service Area from where they lived. Regarding "travelers," for those living in a skilled nursing-only Hospital Service Area, 49.9% traveled for care to Hospital Service Areas with only inpatient rehabilitation and skilled nursing. Patients living in skilled nursing-only Hospital Service Areas had more than five times higher odds of traveling compared to those living in Hospital Service Areas with all three facilities. CONCLUSIONS: Geographically, the vast majority of Hospital Service Areas in the United States that provided rehabilitation services for stroke survivors were skilled nursing-only. However, only about one-third lived in skilled nursing-only Hospital Service Areas; over 35% traveled to receive care. Geographic variation exists in post-acute care; this study provides a foundation to better quantify its drivers. This study presents previously undescribed drivers of variation in post-acute care service utilization among Medicare beneficiaries-the "traveler effect".

A Pilot Survey: Knowledge of Charcot Neuroarthropathy Among Family and Internal Medicine Practitioners.

Charcot neuroarthropathy secondary to diabetes mellitus is a serious complication, requiring specialist management. As a relatively rare pathology bearing similarity to other, more common diseases, it may be misdiagnosed at initial presentation, potentially leading to delays in appropriate management. We conducted a 2-part online survey of primary care physicians within an academic medical institution to assess knowledge of presentation, complications, diagnosis, and treatment of Charcot neuropathy. The first section was designed to assess physician knowledge of Charcot foot, while the second section was completed only by physicians who were familiar with the condition and was designed to gauge their level of knowledge. Most clinicians were familiar with Charcot, encountering it at least annually. They identified common signs of Charcot (eg, swelling, pain) and complications due to its mismanagement (eg, ulcer, amputation). However, there was some disagreement on how to diagnose the pathology, with some relying on film, others referring to specialists, and some saying they were unsure. There was uncertainty on when to choose surgical options; fewer than half referred to specialists for help with this decision, and a quarter were unsure how to make the decision. While, in general, clinicians were aware of Charcot and its characteristics, there was confusion regarding how to diagnose or appropriate nonsurgical treatment.

Thromboprophylaxis and Bleeding Complications in Orthopedic and Trauma Patients: A Systematic Review.

This systematic review was conducted to investigate the effects of currently used chemoprophylactic modalities to assess concerns regarding their usage. Preventive benefits of thromboprophylaxis were weighed against potential complications in orthopedic and trauma patients. The Ovid MEDLINE® database was used to identify relevant studies. The authors independently screened the initial study articles by title and abstract, eliminating articles not dealing with venous thromboembolism (VTE) chemoprophylaxis in orthopedic or trauma populations. The remaining articles were assessed for eligibility through full-text analysis. The analyzed studies within this review suggested that Factor Xa inhibitors and direct oral anticoagulants hold promise as safe and potentially more effective thromboprophylactic entities when compared to low molecular weight heparin in trauma and orthopedic patients. Thromboprophylaxis had little to no effect on major bleeding incidence, although we could not definitively conclude there was no effect on overall bleeding. Early thromboprophylaxis, especially when identifiable risk factors are present, can improve VTE prevention without changing major bleeding rates. Additionally, we could not conclude whether extended prophylaxis affects VTE incidence, although it seemed to have no effect on major bleeding. Finally, we determined that thromboprophylaxis in the lower extremity trauma population is questionable without the presence of underlying risk factors.