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By: Karen Patton Alexander, MD

  • Professor of Medicine
  • Member in the Duke Clinical Research Institute

Suturing versus conservative management of lacerations of the hand: randomised controlled trial . Aesthetic and functional efficacy of subcuticular running epidermal closures of the trunk and extremity: a rater-blinded randomized control trial . Single-layer versus double-layer closure of facial lacerations: a randomized controlled trial . A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures. A comparison of dexon (polyglycolic acid) sutures with other commonly used sutures in an accident and emergency department. Absorbable versus nonabsorbable sutures in the management of traumatic lacerations and surgical wounds: a meta-analysis. Randomised trial of histoacryl blue tissue adhesive glue versus suturing in the repair of paediatric lacerations. A prospective comparison of octyl-2-cyanoacrylate and suture in standardized facial wounds. Cosmetic outcomes of facial lacerations repaired with tissue adhesive, absorbable, and nonabsorbable sutures. A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. Tissue adhesive versus suture wound repair at 1 year: randomized clinical trial correlating early, 3-month, and 1-year cosmetic outcome. Prospective randomized blind controlled trial comparing sutures, tape, and octylcyanoacrylate tissue adhesive for skin closure after phlebectomy. Closure of lacerations and incisions with octylcyanoacrylate: a multicenter randomized controlled trial. A single blind, prospective, randomized trial comparing n-butyl 2-cyanoacrylate tissue adhesive (Indermil) and sutures for skin closure in hand surgery. Comparison of tissue adhesive and suturing in the repair of lacerations in the emergency department. A randomised, controlled trial comparing a tissue adhesive (2 octylcyanoacrylate) with adhesive strips (Steristrips) for paediatric laceration repair. Prospective comparison of cosmetic outcomes of simple facial lacerations closed with Steri-Strips or Dermabond. A randomized, controlled trial comparing a tissue adhesive with suturing in the repair of pediatric facial lacerations. A randomized, clinical trial comparing butylcyanoacrylate with octylcyanoacrylate in the management of selected pediatric facial lacerations. Evaluation of a new high-viscosity octylcyanoacrylate tissue adhesive for laceration repair: a randomized, clinical trial. A prospective, randomised evaluation of aesthetic outcomes in patients undergoing elective day-case hand and wrist surgery. Cross-suturing as an aid to wound closure: a prospective randomised trial using the forearm flap donor site as a model. Comparison of local infiltration anesthesia and peripheral nerve block: a randomized prospective study in hand lacerations. A prospective comparison of octyl cyanoacrylate tissue adhesive (dermabond) and suture for the closure of excisional wounds in children and adolescents. Formation of the scab and the rate of epithelization of superficial wounds in the skin of the young domestic pig. Effectiveness of penicillin irrigation in control of infection in sutured lacerations. A comparative double blind study of amoxycillin/clavulanate vs placebo in the prevention of infection after animal bites. A clinical trial using co-trimoxazole in an attempt to reduce wound infection rates in dog bite wounds. Prospective analysis of splinting the first carpometacarpal joint: an objective, subjective, and radiographic assessment. Reduction in the need for operation after conservative treatment of osteoarthritis of the first carpometacarpal joint: a seven year prospective study. The effects of strength training among persons with hand osteoarthritis: a two-year follow-up study. Joint protection and home hand exercises improve hand function in patients with hand osteoarthritis: a randomized controlled trial.

Second , and perhaps most important , is how to determine when a member of the organization is sleep deprived. These are just a few of the questions that this study can help a fire chief answer. Sleep deprivation is linked with increased errors in tasks requiring alertness, vigilance and quick decision-making. Long work hours often are associated with chronic sleep loss, which may result in decreased ability to think clearly and feelings of depression, stress and irritability. Those effects are not reliably predicted by how fatigued an individual feels, as chronically sleep deprived people frequently do not perceive their lack of sleep as a problem. Chronic sleep loss also is associated with a general increase in health complaints and musculoskeletal problems, higher body weights, a greater risk of obstructive sleep apnea and heightened levels of cardiovascular disease and cancer. The challenge is to achieve the benefits of a given work structure while minimizing the potential decrements in performance and cumulative adverse health effects that long work hours and acute and chronic sleep deprivation may have on workers. We begin this report with background on the physiology of sleep, followed by a critical review of the immediate effects of fatigue and the health and performance consequences of chronic sleep deprivation. In Section 1, we outline the caveats and potential limitations when reviewing compiled research from varied settings. In presenting studies, we have included information about the group assessed and methodology to assist interpretation of those reports. The transportation industry and more recently postgraduate medical training are settings where fatigue-related adverse events have mandated examination of work hours effects, shift structure reform and attention to fatigue countermeasures. Again, study details are presented and compiled findings tabulated, which will allow readers to appropriately draw conclusions from observations in varied settings. Section 5 presents science-based recommendations for individuals and organizations concerning managing work hours, including means to identify workers at greater risk from long hours, mitigating individual lifestyle actions and employer work-structure issues. The Appendices in Section 6 include legal considerations and the authors recommendations in the domains of education and potential future studies. By including these suggestions in the final Section, we underscore that these are the opinions of the authors. Involving all stakeholders (personnel and their families, management, representatives from labor organizations and national administrative bodies, and sometimes outside consultants) is critical to the success of any fatigue management program. In other settings, highly publicized fatigue-related adverse events have necessitated reform. In this report, we re received more attention from poets and other writers view the effects of sleep deprivation for (Dement, 2000). We have come to appreciate how important healthy sleeping habits are to well being. Sleep, or lack of it, impacts humans abilities and both psychological and physiological health. Understanding each is important for interpreting studies of the effects of differing work hours on health. Humans are by nature diurnal (day orientated) as opposed to nocturnal (night orientated), meaning that our physiological functions are geared towards daytime activity and nighttime rest. Because of humans circadian rhythm and preference for nighttime sleep, all sleeping hours are not equal. When assessing the effects of a given daily schedule, both the number of hours slept and the time that they occurred must be considered. Stage 1 is viewed as a shallow sleep during which an individual can be easily awakened. This cycling and ness, problem-solving and short-term memory all de organization of the sleep stages constitute the crease from midnight until the following morning. The most readily measured index of that daily progression is body temperature, shown in the lowest panel of Figure 1. The subjects alert-ness is shown just above body temperature, and that remains fairly stable during the day, with a slight dip late in the afternoon.

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Selection bias: Error due to systematic differences in characteristics between those who are selected for study and those who are not . In assessments of the validity of studies of healthcare interventions , selection bias refers to systematic differences between comparison groups in prognosis or responsiveness to treatment. Random allocation with adequate concealment of allocation protects against selection bias. Other means of selecting who receives the intervention of interest, particularly leaving it up to the providers and recipients of care, are more prone to bias because decisions about care can be related to prognosis and responsiveness to treatment. Selection bias, confusingly, is also sometimes used to describe a systematic difference in characteristics between those who are selected for study and those who are not. This affects the generalizability (external validity) of a study but not its (internal) validity. Sensitivity: the proportion of truly diseased persons, as identified by the diagnostic "gold standard" who are identified as diseased by the diagnostic test under study. Single blind: the investigator is aware of the treatment/intervention the participant is getting, but the participant is unaware. Specificity: the proportion of truly nondiseased persons, as identified by the diagnostic "gold standard," who are identified as nondiseased by the diagnostic test under study. Spectrum bias: when the population under investigation does not reflect the general population or the clinically relevant population. In studies of the effectiveness of healthcare interventions, power is a measure of the certainty of avoiding a false negative conclusion that an intervention is not effective when in truth it is effective. The power of a study is determined by how large it is (the number of participants), the number of events. Statistically significant: an estimate of the probability of an association (effect) as large or larger than what is observed in a study occurring by chance, usually expressed as a P-value. Although it is often done, it is inappropriate to interpret the results of a study differently according to whether the P-value is, say, 0. Note the distinction between clinical and statistical significance; clinical significance is the more important. For example, when large numbers of comparisons are made, some differences will be "statistically significant" by chance; i. Strength of inference: the likelihood that an observed difference between groups within a study represents a real difference rather than mere chance or the influence of confounding factors, based on both p values and confidence intervals. Strength of inference is weakened by various forms of bias and by small sample sizes. Syndrome: a symptom complex in which the symptoms and/or signs coexist more frequently than would be expected by chance on the assumption of independence. Systematic error: deviation of the results or inferences from the truth, or processes leading to such deviation. Systematic review: a review of a clearly formulated question that uses systematic and explicit methods to identify, select and critically appraise relevant research, and to collect and analyze data from the studies that are included in the review. Statistical methods (meta-analysis) may or may not be used to analyze and summarize the results of the included studies. Many studies have small sample sizes that make it difficult to reject the null hypothesis, even when there is a big change in the data. It is not an error in the sense that an incorrect conclusion was drawn since no conclusion is drawn when the null hypothesis is not rejected. Validity: the extent to which a variable or intervention measures what it is supposed to measure or accomplishes what it is supposed to accomplish. The internal validity of a study refers to the integrity of the experimental design. The external validity of a study refers to the appropriateness by which its results can be applied to non-study patients or populations. Validity is the degree to which a result (of a measurement or study) is likely to be true and free of bias (systematic errors). Validity has several other meanings, usually accompanied by a qualifying word or phrase; for example, in the context of measurement, expressions such as "construct validity", "content validity" and "criterion validity" are used.

Fragility , as measured by deaths per driver involved in a crash , begins to increase at ages 60 to 64 and increases steadily with advancing age. Fragility, rather than an increased tendency to get into crashes, accounts for about 60% to 95% (depending on age group and gender) of the increased death rates per miles traveled in older drivers (Li, 2003). Strategies to Reduce Crashes and Injuries Involving Older Drivers the overall goal is to enable older drivers to retain as much mobility through driving as is consistent with safety on the road for themselves, their passengers, and other road users. This can be accomplished through formal courses or through communications and outreach provided directly to older drivers or to families, friends, and organizations that deal regularly with older drivers. This involves two steps: o Bring these drivers to the attention of the motor vehicle department through license renewal procedures or through referral from law enforcement, physicians, family, or friends. Vehicular, environmental, and societal strategies are critical to provide safety and mobility for older people. Vehicles can be designed with better crash protection for older and more easily injured occupants, with controls and displays that are easier to see, reach and understand, and with crash warning and crash avoidance technology. These measures will make vehicles safer for 7 3 everyone, not just older people. Aftermarket vehicle devices such as one-hand joystick driving controls can make driving possible or easier for people with some physical limitations. Roadways with separate left turn lanes, protected left turn signal phases, larger and more-visible signage, more-visible lane markings, rumble strips, and a host of other measures will assist all drivers. Of all the subject areas in this guide, those related to older drivers are perhaps the most complex because they involve so many issues beyond traffic safety. Sooner or later, in the interest of safety, most older drivers must restrict or eliminate driving, either by choice or by force. State Highway Safety Offices and licensing agencies cannot act alone but must plan and implement their older driver policies and programs as part of integrated community activities to improve older people safety, mobility, and health. As just one example, some communities have established referral centers where people can go for one-stop access to resources for addressing the full range of transportation safety and mobility issues, including driving skills assessment, educational courses, licensing regulations and practices, and public transportation. See Stutts (2005) for summaries of comprehensive programs for older drivers in 6 States. Effectiveness, cost, and time to implement can vary substantially from State to State and community to community. Costs for many countermeasures are difficult to measure, so the summary terms are very approximate. Use: High: more than two-thirds of the States, or a substantial majority of communities Medium: between one-third and two-thirds of States or communities Low: fewer than one-third of the States or communities Unknown: data not available Cost to implement: High: requires extensive new facilities, staff, equipment, or publicity, or makes heavy demands on current resources Medium: requires some additional staff time, equipment, facilities, and/or publicity Low: can be implemented with current staff, perhaps with training; limited costs for equipment or facilities these estimates do not include the costs of enacting legislation or establishing policies. Time to implement: Long: more than one year Medium: more than three months but less than one year Short: three months or less these estimates do not include the time required to enact legislation or establish policies. The courses typically involve 6 to 10 hours of classroom training in basic safe driving practices and in how to adjust driving to accommodate age-related cognitive and physical changes. Use: Courses are taught in all States but reach only a small fraction of older drivers. The most thorough evaluation studied approximately 200,000 course graduates and a 360,000-driver comparison group in California from 1988 to 1992. A study conducted in 2004 evaluated the effects of a well-designed three-hour educational course promoting safe driving strategies for older drivers with some visual defects. Course graduates reported that they regulated their driving more following the course than a control group that did not attend the course. There was no significant difference in crash rates between course graduates and the control group (Owsley, McGwin, Phillips, McNeal, & Stalvey, 2004). Another 2004 study involving a systematic review of studies evaluating the effectiveness of driver retraining programs (Kua, Korner-Bitensky, Desrosiers, Man-Song-Hing, & Marshall, 2007) reached a similar conclusion as did Owsley et al. These researchers reported that while there is moderate evidence that educational interventions improve driving awareness and behavior, these interventions do not reduce crashes in older drivers. Regardless, the authors felt 7 7 that the evidence regarding the effectiveness of retraining aimed at older drivers is encouraging enough warrant further research. More recent evaluations of courses for older drivers have produced mixed results related to the crash rates of drivers attending these courses.