Background:Human locomotion is a highly adaptive motor skill that adjusts to new environmental demands through learning. Split-belt treadmill paradigms have advanced our understanding of gait adaptation. Most studies have examined gait when the belts move at different speeds in the same direction. We are studying muscle activation patterns during an asymmetric gait, when the treadmill belts move at equal speed in opposite directions, i.e., bidirectional walking (BDW). Methods:Twelve healthy volunteers performed a single session on a split-belt treadmill. We simultaneously collected ground reaction forces via treadmill force plates, joint kinematics via motion capture, and surface electromyography (EMG) from bilateral soleus (SOL) and tibialis anterior (TA) muscles. Participants started with 2 min of forward walking (FW), followed with four 5-min blocks of BDW separated by 1-min standing rest intervals, and finished the session with 2 min of FW (washout). Results:All participants successfully completed the protocol. We analyzed EMG signals for temporal activation patterns (rhythm generation) and amplitude characteristics (pattern formation). EMG recordings revealed antiphasic activation of SOL and TA muscles bilaterally throughout all trials. During BDW, the backward-moving leg's TA showed prolonged activation patterns that persisted during washout FW, suggesting retention of adaptive changes. Burst-to-cycle duration ratios showed transient changes during early adaptation but remained relatively stable across conditions, demonstrating robust rhythm generation despite adaptive modulation of activation patterns during BDW. Discussion:These findings demonstrate that BDW induces asymmetric adjustments in muscle activation patterns. Rhythm generation (timing) did not significantly differ between BDW and FW. However, we did observe changes in pattern formation (i.e., EMG profiles) during FW pre- and post-BDW training. Burst-to-cycle duration ratios, as a measure of rhythm generation, showed changes during early adaptation, particularly the increase in right SOL and right TA during block 1, though these changes did not reach statistical significance and largely returned to baseline during washout. The underlying pattern formation structure, was maintained across all conditions, with selective amplitude modulations rather than fundamental reorganization of activation patterns. The substantial temporal adjustments in the backward-moving leg's SOL and phase shifts in TA provide the neuromuscular mechanism driving the bilateral step-length reduction, altered inter-limb phasing, and asymmetric double stance timing. These results extend our understanding of locomotor control by suggesting how the central nervous system (CNS) dynamically recalibrates muscle timing and amplitude to maintain satisfactory locomotion under new environmental demands.

Open air burn pits were used extensively during military operations in Iraq and Afghanistan, potentially exposing millions of US Veterans to toxic airborne hazards. Many of the airborne toxins released have been shown to induce lung inflammation and lung injury and are mutagenic. This is the first large-scale study of associations between self-reported burn pit exposures and the development of cancer. Using data from the Airborne Hazards and Open Burn Pit Registry, we found that Veterans reporting burn pit exposures are associated with a higher odds of developing cancer. However, investigations into the development of specific type of cancer and into a burn pit exposure dose-response effect were inconclusive. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by the VA Airborne Hazards and Burn Pits Center of Excellence Pilot Project Program (#FY2024-001). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: IRB of the Stratton VA Medical Center gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data used for this study are the property of the US Department of Veterans Affairs. The authors are unable to provide access to the data.

The 2016 AUA guidelines aimed to change urethral stricture management from multiple endoscopic treatments to a single endoscopic treatment followed by urethroplasty if necessary. We analyzed treatment patterns of Veterans with urethral stricture disease before and after the 2016 guidelines. We queried the VA Corporate Data Warehouse from January 1, 2000 to October 18, 2023 to identify Veterans with a urethral stricture diagnosis and Veterans who underwent endoscopic treatment or urethroplasty. We assessed the number of endoscopic procedures and progression to urethroplasty. We compared the number of endoscopic treatments prior to urethroplasty between the pre-guidelines (2000–2015) and post-guidelines (2017–2023) periods using negative binomial regression and time to urethroplasty after the first endoscopic treatment using a log-rank test. We identified 148,067 male veterans for analysis. 84,931 (57.3

BACKGROUND:Previous clinical data suggest that the presence of a pleural effusion is associated with poor survival. However, these studies were limited by either a small sample size or lack of an adequate control group. RESEARCH QUESTION:What is the impact of pleural effusion on survival in patients hospitalized with an admitting diagnosis of the 3 most common causes of pleural effusion: cancer, congestive heart failure, or pneumonia? STUDY DESIGN AND METHODS:This is a retrospective analysis of US veterans hospitalized between January 1, 2000 and December 31, 2020. International Classification of Diseases codes were used to identify patients with an admitting diagnosis of congestive heart failure (CHF), pneumonia, or cancer. Patients were dichotomized as having a clinically significant pleural effusion (PE) when a PE drainage was performed or not. The latter group included both patients who had a PE that was not clinically significant (did not require drainage) and those who did not have a PE at the time of index hospitalization (NO-PE). All-cause mortality was compared between the PE and NO-PE cohorts. RESULTS:We analyzed 34,707 patients in the PE group and 792,217 patients in the NO-PE group. Patients with PE had a significantly higher all-cause mortality compared with patients with no PE. The median survival time was significantly lower in PE group as compared with NO-PE group across all 3 diagnoses, CHF (PE, 1.51 years; 95% CI, 1.40-1.61 vs NO-PE, 3.23 years; 95% CI, 3.21-3.26), cancer (PE, 1.33 years; 95% CI, 1.27-1.39 vs NO-PE, 2.05 years; 95% CI, 2.02-2.08), and pneumonia (PE, 4.27 years; 95% CI, 3.94-4.61 vs NO-PE, 5.11 years; 95% CI, 5.06-5.15). The hazard ratios of all-cause mortality remained unchanged after adjusting for demographics and comorbidities. INTERPRETATION:The presence of a clinically significant PE was independently associated with higher all-cause mortality in patients with admitting diagnosis of CHF, cancer, and pneumonia. Clinicians and researchers should consider the association of CHF, cancer, and pneumonia with PEs when estimating the prognosis of individual patients and when assessing the survival of longitudinal cohorts.

INTRODUCTION:Benign prostatic hyperplasia (BPH) epidemiology has been broadly investigated. However, less is known about how race affects BPH diagnosis and management. This study analyzed racial trends in the diagnosis and surgical management of BPH among US veterans. METHODS:The Veterans Affairs (VA) Corporate Data Warehouse database was queried from January 1, 2000, to October 20, 2024, to identify veterans with a diagnosis of BPH. We assessed the rates of BPH procedures and compared trends in diagnosis and surgical management across different demographics including race. RESULTS:We identified 532,886 veterans with BPH. Black men were diagnosed at a younger age (63.1 years) compared with White men (66.7 years, P < .01). Black men had a lower rate of surgical management (12.2%) compared with White men (14.6%, P < .01). On Cox regression, Black men had a lower likelihood of surgery when controlling for age and comorbidity status (HR 0.87, 95% CI [0.85-0.89], P < .01). Black men experienced a longer interval between diagnosis and surgery compared with White men (5.2 vs 4.7 years, P < .01). Black men had the lowest rate of transurethral resection of the prostate (65.8%) but had the highest rate of simple prostatectomy (6.7%). CONCLUSIONS:As veterans have equal health care access through the VA system, our study provides an analysis of BPH management that is unaffected by insurance coverage disparities. Black men were diagnosed with BPH at a younger age, underwent fewer surgical procedures, and had a longer interval between diagnosis and surgery compared with White men. These findings demonstrate significant racial variations, which further examine previously realized racial disparities in health care.

Humans can acquire and maintain motor skills throughout their lives through motor learning. Motor learning and skill acquisition are essential for rehabilitation after neurological disease or injury. Adaptation, the initial stage of motor learning, involves short-term changes in motor performance in response to a new demand in the person's environment. Repeated adaptation can improve skill performance and result in long-term skill retention. Locomotor adaptation has been extensively studied with split-belt treadmill paradigms. In this study we explored whether bidirectional walking (BDW) on a split-belt treadmill can induce short-term gait adaptations. Twelve healthy volunteers participated in our single session, starting with 2 min of forward walking (FW), followed by four 5-min blocks of BDW with a 1-min passive rest in between blocks, and ending with another 2-min block of FW. We recorded body kinematics and ground reaction forces throughout the experiment. Participants modified both temporal (interlimb phasing, double stance duration) and spatial (step length) aspects of gait to meet the mechanical demands of backward dual walking (BDW). Adaptation occurred rapidly, with bilateral reductions in step length, adjustments in stance and swing phase timing, alterations in interlimb phasing, and decreased double stance duration in the limb walking backward. Notably, only the backward-walking limb (right) exhibited persistent aftereffects upon return to FW. These results demonstrate that BDW elicits adaptations in both spatial and temporal gait parameters, with transient aftereffects consistent with short-term motor learning. To our knowledge, this is the first report characterizing such spatiotemporal adaptations during BDW.NEW & NOTEWORTHY In this study, we demonstrate that bidirectional walking, i.e. walking with symmetrical limb speeds but in opposite directions, induces spatiotemporal adjustments and adaptations that persist for several minutes upon returning to forward walking. This study serves to validate bidirectional walking as a complementary paradigm to other split-belt training paradigms with unique biomechanical characteristics to investigate locomotor adaptation and learning.

Hoffmann reflex (HR) operant conditioning (HROC) is an important intervention for neurorehabilitation. Current HROC paradigms elicit HRs at low rates ( 0.2 Hz), minimizing rate-dependent depression (RDD). We investigated the impact of higher stimulation rates on HR size. Fifteen healthy participants maintained low background soleus electromyographic activity (EMG) while standing. Soleus HR and M-wave recruitment curves were obtained at rates of 0.2, 1, and 2 Hz twice, from which Mmax and Hmax were calculated. Seventy-five HRs were collected for each rate at a target M-wave size ( 10 to 20

Operant conditioning of the spinal stretch reflex or its electrical analog, the H-reflex, induces plasticity in the brain and spinal cord that increases (up-conditioning) or decreases (down-conditioning) the reflex elicited by primary afferent input to the spinal motoneuron. In rats in which the sciatic nerve is transected and repaired, soleus (SOL) H-reflex up-conditioning during regeneration strengthens primary afferent reinnervation of SOL motoneurons and improves recovery of the SOL H-reflex. This suggests that H-reflex up-conditioning could improve functional recovery after nerve injury and repair. To explore this possibility, we examined the impact of SOL H-reflex up- or down-conditioning during sciatic regeneration on recovery of locomotor symmetry. Sprague-Dawley rats were implanted with EMG electrodes in right SOL and a stimulating cuff on right posterior tibial nerve. After control data collection, right sciatic nerve was transected and repaired. Control EMG and H-reflex data collection continued for 20 more days. The rat was then exposed for 100 days to either: continued control data collection; SOL H-reflex up-conditioning; or SOL H-reflex down-conditioning. Locomotor EMG, H-reflex, and kinematics were assessed before nerve transection and 120 days after transection. H-reflex up-conditioning improved H-reflex recovery and also restored right/left step symmetry. H-reflex down-conditioning did not worsen H-reflex recovery or right/left step asymmetry. These results suggest that H-reflex up-conditioning might enhance functional recovery after nerve injury in humans. They also confirm previous results indicating that compensatory plasticity prevents inappropriate H-reflex conditioning (i.e., down-conditioning) from further impairing function.

INTRODUCTION:Eosinophilic esophagitis (EoE) is a chronic esophageal disorder associated with atopy. However, there are few data on prevalence of EoE in atopic patients. We aimed to determine the prevalence of EoE in atopy and associated demographics, risk factors, and symptoms. METHODS:A cross-sectional study was conducted with data from the VA population, 2009-2021, using a 9.7% random sample from a nationwide database. Demographics, symptoms, and risk factors were collected on patients at least one atopic condition. Logistic regression models for EoE, allergy, and symptoms were developed. RESULTS:Of 1,110,189 VA patients, 26% (288,193) had at least one atopic condition and 0.092% (1,022) had an EoE diagnosis. In atopic patients, EoE was most common in patients with milk (4.10%), egg (1.06%), and wheat (0.81%) allergy. Frequency of EoE was lower in patients with asthma (0.26%) and rhinitis (0.22%). Compared to male VA patients without allergy, odds ratio (OR) for EoE was 2.87 for an atopic male, and 3.29 for an atopic female. ORs were increased for EoE in those with milk allergy (OR = 19.9), wheat allergy (OR = 5.94), and egg allergy (OR = 4.10). Of patients with more than one allergic condition, rhinitis and asthma were most likely to increase odds of EoE. CONCLUSION:The prevalence of EoE is substantially increased in atopic patients, and in particular in patients with food allergy. There should be high clinical suspicion for EoE in a patient with atopic disease and especially milk, wheat, or egg allergy.

You have accessJournal of UrologyReconstruction: Urethral Reconstruction (Including Stricture) II (MP32)1 May 2024MP32-06 PRACTICE CHANGES IN URETHRAL STRICTURE MANAGEMENT IN THE US VETERAN POPULATION AFTER THE 2016 AUA GUIDELINES Nikolas Moring, Michael Tram, Darren Gemoets, Charles Welliver, and Brian Inouye Nikolas MoringNikolas Moring , Michael TramMichael Tram , Darren GemoetsDarren Gemoets , Charles WelliverCharles Welliver , and Brian InouyeBrian Inouye View All Author Informationhttps://doi.org/10.1097/01.JU.0001008816.80828.35.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Endoscopic management is often the first line treatment for urethral stricture. Until 2016, the American Urological Association (AUA) did not publish guidelines for urethral stricture treatment. The 2016 AUA guidelines aimed to change the treatment course of stricture disease from multiple endoscopic treatments to a single endoscopic treatment followed by urethroplasty if necessary. We analyzed practice patterns of Veterans Affairs (VA) urologists before and after the 2016 guidelines. METHODS: We queried the VA Corporate Data Warehouse database from 1/1/2000 to 10/18/2023 to identify Veterans with a diagnosis of urethral stricture and Veterans who underwent endoscopic treatment or urethroplasty. We assessed the number of endoscopic procedures performed and progression to urethroplasty. We compared the number of endoscopic treatments prior to urethroplasty between the pre-guidelines (2000-2015) and post-guidelines (2017-2023) periods using negative binomial regression and the time to urethroplasty after the first endoscopic treatment using a log-rank test. RESULTS: We identified 148067 patients with urethral stricture disease. We identified 84931 (57.3%) patients who underwent any treatment. Most patients (n=80669, 95.0%) did not progress to urethroplasty, receiving an average of 1.74 (SD 2.90) endoscopic treatments. There were 4262 patients who underwent urethroplasty and most had no prior endoscopic treatment (n=2735, 64.2%). Of the patients who did have endoscopic treatment prior to urethroplasty (n=1527), there was a reduction in the number of endoscopic treatments prior to urethroplasty, from an average of 2.43 (SD 2.74) to 1.34 (SD 0.70) procedures following the 2016 guidelines, which was independent of race, ethnicity, and age (p<.01). Additionally, in the post-guidelines era, the average time to urethroplasty after the first endoscopic treatment decreased from 1284.2 days to 391.6 days and was significantly shorter on Kaplan-Meier analysis (p<.01, Figure 1). CONCLUSIONS: It appears that the AUA guidelines have had the intended effect of reducing repeat endoscopic procedures prior to urethroplasty among Veterans. These findings demonstrate that Veterans are receiving guideline-adherent care. This helps minimize practice variation while enhancing patient outcomes. Download PPT Source of Funding: None © 2024 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 211Issue 5SMay 2024Page: e516 Advertisement Copyright & Permissions© 2024 by American Urological Association Education and Research, Inc.Metrics Author Information Nikolas Moring More articles by this author Michael Tram More articles by this author Darren Gemoets More articles by this author Charles Welliver More articles by this author Brian Inouye More articles by this author Expand All Advertisement PDF downloadLoading ...

In clinical trials, sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and testosterone replacement therapy (TRT) were shown to stimulate red blood cell production. Little is known if combination therapy poses risk of erythrocytosis in real world clinical practice. This was a retrospective nationwide cohort study of US Veterans with type 2 diabetes (T2D) and baseline hematocrit between 38 and 50

Eosinophilic esophagitis (EoE) is increasing in prevalence but there is a lack of population-based studies. We sought to determine the prevalence, demographics, and associated atopic diseases in the Veterans Affairs (VA) population. A nationwide analysis of data from the VA patient population was done using a Veterans Health Administration database. EoE was identified using ICD9 (530.13) and ICD10 (K20.0) codes from October 2008 to June 2020. Demographic data, smoking status, BMI, treatment, and ICD codes for atopic diagnoses were collected. Two sample proportion z-tests, Chi-square tests, two-sample t tests, and one-way ANOVA were used to assess associations across demographic categories. We identified a total of 11,775 patients with an EoE diagnosis: 91

If Ccr is creatinine clearance and EP and TRP are rates of phosphate excretion and reabsorption, the serum phosphate concentration (Ps) is the sum of EP/Ccr and TRP/Ccr, i.e., the amounts of phosphate excreted and reabsorbed per volume of filtrate. At equilibrium, influx of phosphate into plasma determines EP, and EP/Ccr quantifies the contribution of phosphate influx to Ps. We used data obtained at 688 clinic visits of 387 patients to analyze the evolution of Ps in chronic kidney disease (CKD) stages G1 - 5 (dialysis excluded). EP/Ccr was calculated as (Pu×crs)/cru and TRP/Ccr as Ps-EP/Ccr (where u is urine, s is serum, and cr is creatinine). Means of these parameters were plotted against CKD stages, and correlations among variables were determined with regression analyses. In comparison to values in CKD stages G1 - 2, EP/Ccr rose and TRP/Ccr fell by the same amount in CKD G3a and G3b, and Ps did not change. In stages G4 and G5, EP/Ccr increased sharply, TRP/Ccr fell minimally, and Ps rose significantly. At estimated glomerular filtration rate (eGFR) ≥45 mL/min/1.73m2, TRP/Ccr was the principal determinant of Ps at eGFR < 45 mL/min/1.73m2, contributions of EP/Ccr and TRP/Ccr to Ps were comparable. Taken together, our results show that in CKD stages G4 and G5, the effect of phosphate reabsorption on Ps changes negligibly while that of phosphate influx increases dramatically. Because the tubular response to rising EP/Ccr is limited, maintenance of stable Ps in advanced CKD requires extreme reduction of phosphate influx into plasma. TRP/Ccr may define the lowest attainable Ps.

Humans can acquire and maintain motor skills throughout their lives through motor learning. Motor learning and skill acquisition are essential for rehabilitation following neurological disease or injury. Adaptation, the initial stage of motor learning, involves short-term changes in motor performance in response to a new demand in the person's environment. Repeated adaptation can improve skill performance and result in long-term skill retention. Locomotor adaptation is extensively studied using split-belt treadmill paradigms. In this study we explored whether bidirectional walking (BDW) on a split-belt treadmill can induce short-term gait adaptations. Twelve healthy volunteers participated in our single session, starting with 2 minutes of normal walking (NW), followed by four 5-minute blocks of BDW with a 1-minute passive rest in between blocks, and ending with another 2-minute of NW. We recorded body kinematics and ground reaction forces throughout the experiment. Participants quickly adapted to BDW with both legs showing decreased step lengths. However, only the backward-walking leg exhibited aftereffects upon returning to NW, indicating short-term adaptation. Notable kinematic changes were observed, particularly in hip extension and pelvis tilt, though these varied among participants. Our findings suggest that BDW induces unilateral adaptations despite bilateral changes in gait, offering new insights into locomotor control and spinal CPG organization.

e21049 Background: Lung carcinoids (LC) continue to increase in prevalence and existing data shows a female predominance of these tumors, but relevant epidemiologic data for heterogeneous populations is limited. In this study, we describe the epidemiology of LC in the United States (US) Veteran population. Methods: In this retrospective study, we searched Veteran Affairs Cancer Cube Registry (VACCR) for LC cases diagnosed between 2000 and 2017 and their baseline characteristics. Survival rates were analyzed across all baseline characteristics to identify important prognostic factors and results were compared with Surveillance, Epidemiology, and End Results cancer database (SEER). Data was analyzed via chi-square and Fischer exact probability tests (level of significance at < 0.05). Results: We identified 846 LC cases in VACCR (91% males), and 8,851 LC cases in SEER (32% males). Compared to SEER, VACCR data had more black patients (12% vs 8%), less cases with loco-regional disease (56% vs 84% in SEER) and same proportion of lower lobe tumors (40%). The annual incidence rate of LC among all lung cancers in Veterans tripled from 2000 to 2017 (0.3% to 0.9%). No racial disparities in treatment were noted among the Veterans. Male-specific 5-year survival rate was 18% lower in VACCR compared to SEER (61% vs 79%). Univariate analysis of both databases showed a statistically significant association of survival with age, primary tumor site and gender (p < 0.05 for all) (Table 1), with advanced age, upper lobe LC and male gender associated with worse survival. SEER subgroup analyses also showed lower 5-year survival rates for males across all baseline characteristics. Overall, black race appeared to be associated with worse prognosis, but the results did not reach statistical significance for VACCR data. Conclusions: Our study showed that US Veteran population, consisting of older males with more comorbidities, LC have lower survival rates than SEER population with more female LC cases. Advanced age, upper lobe predominant disease, and advanced stage were associated with worse survival. Both SEER and VACCR data suggest that male sex is a poor prognostic factor for LC. [Table: see text]

H-reflex conditioning is a novel targeted-neuroplasticity-based method for the rehabilitation of movement that uses visual feedback to train participants to change the excitability of their reflexes over several months. Present H-reflex conditioning protocols require experimenters to manually control multiple covariates of the H-reflex to ensure the accuracy of the visual feedback. Manual control of these covariates is error prone, labor intensive, and reduces experimenter engagement with participants. Here, as a first step towards a system that automatically ensures the accuracy of visual feedback during H-reflex conditioning, we performed inference and prediction based on multivariate linear regression (MLR) to assess the effect of six covariates of the size of the H-reflex and whether this class of models can be used to predict those effects. Four participants completed experiments where we measured H-reflex size changes in response to changes in each of the six covariates. Inference from the MLR models show that background EMG activity and stimulation current affected H-reflex size in three of the four participants. In addition, our experiments show that MLR models can be used to predict H-reflex size. Compared to an intercept-only model, MLR reduced prediction error by more than 30% (p < 0.05). Our results suggest that automatic adjustment (in response to changes in covariates of the H-reflex) of visual feedback during H-reflex conditioning is possible. With further development, this method could improve feedback during H-reflex operant conditioning, reduce the need for clinicians and researchers to manually control covariates of the H-reflex, and lead to improved H-reflex conditioning protocols for the rehabilitation of movement following neurological injury or illness.