human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Abstract Introduction The clinical success of total knee arthroplasty ( TKA ) depends substantially on the quadriceps muscle function . A frequently applied thigh tourniquet during TKA may induce ischemia related injuries to quadriceps muscle cells . Animal limb muscles subjected to 2–5 h ischemia revealed dysfunctional mitochondria , which in turn compromised the cellular bioenergetics and increased the level of reactive oxygen species . The hypothesis of the present study was that tourniquet application during TKA for 60 min ( min ) affects the amount and function of mitochondria within musculus vastus medialis cells . Material s and methods In a r and omized clinical trial , 10 patients enrolled to undergo primary TKA . The patients were r and omly assigned to the tourniquet ( n = 5 ) or non-tourniquet group ( n = 5 ) after obtaining a written informed consent . For each of the groups , the first muscle biopsy was harvested immediately after performing the surgical approach and the second biopsy exactly 60 min later . All biopsies ( 5 × 5 × 5 mm ) 125 mm3 were harvested from musculus vastus medialis and snap-frozen in liquid nitrogen . The biochemical analysis of the prepared muscle tissues included the measurement of activities of mitochondrial respiratory chain enzyme complexes I – III and citrate synthase . Results Tourniquet-induced 60 min ischemia time did not significantly change the activities of the mitochondrial respiratory chain enzymes complexes I – III of the skeletal muscle cells . The citrate synthase activities found to be not significantly different between both groups . Conclusions The use of tourniquet during TKA within a limited time period of 60 min remained without substantial effects on the amount and function of mitochondria within human skeletal muscle cells Tourniquet pain is a common source of complaint for patients undergoing carpal tunnel decompression and practice varies as to the tourniquet position used . There is little evidence to suggest benefit of one position over another . Our aim was to compare patient and surgeon experience of forearm and arm tourniquets . Following a power calculation , 100 patients undergoing open carpal tunnel decompression under local anaesthetic  were r and omized to either an arm or a forearm tourniquet . Measurements of blood pressure , heart rate and pain were taken at 2.5 min intervals . The operating surgeon also provided a visual analogue scale rating for the extent of bloodless field achieved and for any obstruction caused by the tourniquet . There was no statistically significant inter-group difference in patient pain or physiological response , tourniquet time , bloodless field or length of procedure . The degree of obstruction caused by the tourniquet was significantly higher in the forearm group . Level of Evidence : I. Prospect i ve R and omized Controlled OBJECTIVE Lactate levels are increasingly used to guide resuscitation efforts . Some surgical literature suggests that tourniquet use during phlebotomy falsely elevates results , although studies in healthy volunteers have not demonstrated this . The purpose of this study was to determine in clinical practice whether tourniquet use during the drawing of a lactate results in significantly altered levels compared to the result of a level drawn without a tourniquet . METHODS A prospect i ve cohort study was carried out on emergency department patients whose clinical presentation led a physician to order a lactate level . Written informed consent was obtained from patients or their proxies . Study  lactates  were obtained using a tourniquet during the draw sequence of other laboratory studies . Lactate levels for clinical use were drawn per hospital protocol with no tourniquet . The time of lactate measurements and patient demographic information were recorded . Lactate levels for each patient were compared with the Wilcoxon Rank-Sum Test . RESULTS 40 patients were consented and enrolled . The median clinical lactate level was 1.9 ( interquartile range 1.5 - 2.6 ) , and the median study lactate level was 1.9 ( interquartile range 1.4 - 2.7 ) . There was no difference between paired lactate values ( p=0.95 ) . CONCLUSIONS Tourniquet use appears to have no impact on measured lactate levels . Our findings suggest that current practice s at many institutions regarding lactate collection are likely too stringent and should be changed AIM Thigh pain following tourniquet application is a common complaint in early post operative period following total knee arthroplasty . METHOD Post operative Thigh pain was evaluated in 30 consecutive simultaneous bilateral total knee arthroplasty patients between July 2013 and January 2014 . Patient thigh pain was evaluated with the VAS score . The scale was applied on first , second , third day & second and six weeks after surgery . RESULT There were statistically significant difference in VAS score  in non-tourniquet group on first , second , third post operative day . We did not find statistically significant difference at Second and Six weeks post operatively . CONCLUSION This R and omized trial demonstrates that non-tourniquet use in TKA has less early postoperative pain and leads to better recovery Background In a care under fire situation , a first line response to haemorrhage is to apply a tourniquet and return fire . However , there is little underst and ing of how tourniquets and other haemorrhage control devices impact marksmanship . Methods We compared the impact of the iTClamp and the Combat Application Tourniquet ( CAT ) on marksmanship . Following r and omisation ( iTClamp or CAT ) , trained marksmen fired an AR15 at a scaled silhouette target in prone unsupported position ( shooting task ) . Subjects then attempted to complete the shooting task at 5 , 10 , 15 , 30 and 60 min post-haemorrhage control device application . Results All of the clamp groups ( n=7 ) completed the 60 min shooting task . Five CAT groups ( n=6 ) completed the 5 min shooting task and one completed the 5 and 10 min shooting task before withdrawing . Four CAT groups were stopped due to unsafe h and ling ; two stopped due to pain . When examining hits on mass ( HOM ) for the entire shooting task , there was no significant difference between tourniquet and iTClamp HOM at 5 min ( p=0.18 ) . However , there was a significant difference at 10 min , p=0.003 with tourniquet having significantly fewer HOM ( 1.7±2.7 HOM ) than the iTClamp ( 8.1±3.3 HOM ) group . The total effective HOM for the entire 60 min shooting task showed that the iTClamp group achieved significantly ( p=0.001 ) more HOM than the tourniquet group . Over the entire 60 min shooting exercise , the iTClamp group achieved a median 72 % ( 52/72 ) of available HOM while the tourniquet group obtained 19 % ( 14/72 ) . Conclusions Application of a tourniquet to the dominant arm negates effective return of fire in a care under fire setting after a brief time window . Haemorrhage control devices that preserve function may have a role in care under fire situations , as preserving effectiveness in returning fire has obvious operational merits BACKGROUND The widespread application of tourniquets has reduced battlefield mortality related to extremity exsanguinations . Tourniquet-induced ischemia-reperfusion injury ( I/R ) can contribute to muscle loss . Postischemic conditioning ( PostC ) confers protection against I/R in cardiac muscle and skeletal muscle flaps . The objective of this study was to determine the effect of PostC on extremity muscle viability in an established rat hindlimb tourniquet model . METHODS Rats were r and omly assigned to  PostC-1 , PostC-2 , or no conditioning ischemic groups ( n = 10 per group ) .  Postischemic conditioning , performed immediately after tourniquet release , consisted of four 15-second cycles ( PostC-1 ) or eight 15-second cycles ( PostC-2 ) of alternating occlusion and perfusion of hindlimbs . Twenty-four hours later , muscles were excised . The primary end points were muscle edema and viability ; secondary end points were histologic and markers of oxidative stress . RESULTS Ischemia-reperfusion injury decreased viability in all tourniquet limbs , but viability was not improved in either PostC group . Likewise , I/R result ed in substantial muscle edema that was not reduced by PostC. The predominant histologic feature was necrosis , but no significant differences were found among groups . Markers of oxidative stress were increased similarly among groups after I/R , although myeloperoxidase activity was significantly increased only in the no conditioning ischemic group . A protective effect from PostC was not observed in our model suggesting that PostC was not effective in reducing I/R skeletal muscle injury or any benefits of PostC were not sustained for 24 hours when tissues were assessed . CONCLUSION These negative findings are pertinent as the military investigates different strategies to extend the safe time for tourniquet application OBJECTIVE To determine whether a color-coded tourniquet design ed for public use increases successful tourniquet application by laypeople . METHODS This was a r and omized study conducted on April 25 , 2015 . The study occurred during the Maryl and Day activity at the University of Maryl and in College Park , Maryl and . Investigators recruited participants with posters displayed at major crosswalks around a central testing area . A total of 157 volunteers aged 18 years or older and without prior military service or medical training were enrolled . A participant stood in front of a waist-down mannequin with an isolated leg injury while an investigator read aloud a mass causality scenario . The investigator then asked the participant to apply a tourniquet to the mannequin 's leg . All participants received a 4-step illustrated just-in-time ( JiT ) instruction card design ed to facilitate layperson tourniquet application . Test participants received a color-coded tourniquet design ed for layperson use with instructions printed on the device . Control participants received a black Combat Application Tourniquet ( C-A-T ; Composite Re sources , Rock Hill , SC ) . Participants were r and omized in a 1:1 ratio in blocks of 50 . The primary outcome was the proportion of successful tourniquet applications by those who received color-coded tourniquets compared to those who received black tourniquets . Secondary outcomes included validation of previous data analyzing layperson success with tourniquet application , time for successful placement , reasons for failed applications , and participant self-willingness and comfort using tourniquets . We also analyzed demographic data on the study population and inter-rater reliability regarding the assessment of successful tourniquet application . RESULTS Participants supplied with color-coded tourniquets  successfully placed the device 51.38 % of the time , compared to 44.71 % of the time for controls using a black tourniquet ( risk ratio : 1.15 ; 95 % confidence interval : 0.83 - 1.59 ; P=0.404 ) . Participants  ' self-reported willingness to use a tourniquet rose from 40.8 % before the study to 80.3 % after the study ( P<0.05 ) . CONCLUSIONS The color-coded device did not significantly increase laypeople 's proportion of successful tourniquet applications when compared with a st and ard black device . However , this study reproduced pilot study data showing that laypeople can successfully apply tourniquets about half the time if provided JiT instructions . Age , sex , race , income , and highest level of education were not found to impact one 's ability to properly apply a tourniquet . Laypeople 's willingness to apply tourniquets doubled to 80 % after brief exposure to the device . These results affirm the feasibility of engaging laypeople as immediate lifesavers of trauma victims and justify further efforts to boost rates of proper application BACKGROUND Trauma procedural and management skills are often learned on live tissue . However , there is increasing pressure to use simulators because their fidelity improves and as ethical concerns increase . We r and omized military medical technicians ( medics ) to training on either simulators or live tissue to learn combat casualty care skills to determine if the choice of modality was associated with differences in skill uptake . METHODS Twenty medics were r and omized to trauma training using either simulators or live tissue .  Medics were trained to perform five combat casualty care tasks ( surgical airway , needle decompression , tourniquet application , wound packing , and intraosseous line insertion ) . We measured skill uptake using a structured assessment tool . The medics also completed exit question naires and interviews to determine which modality they preferred . RESULTS We found no difference between groups trained with live tissue versus simulators in how they completed each combat casualty care skill . However , we did find that the modality of assessment affected the assessment score . Finally , we found that medics preferred trauma training on live tissue because of the fidelity of tissue h and ling in live tissue models . However , they also felt that training on simulators also provided additional training value . CONCLUSION We found no difference in performance between medics trained on simulators versus live tissue models . Even so , medics preferred live tissue training over simulation . However , more studies are required , and future studies need to address the measurement bias of measuring outcomes in the same model on which the study participants are trained . LEVEL OF EVIDENCE Therapeutic/care management study , level II Abstract Purpose Recent data suggest diminished post-operative quadriceps muscle strength after tourniquet application  during total knee arthroplasty ( TKA ) . The metabolic effects of the commonly utilized intraoperative tourniquet with consecutive ischaemia on the skeletal muscle cells were unknown . Ubiquitin proteasome system represents one of the main pathways involved in muscle protein breakdown contributing to muscle atrophy . Therefore , the purpose of the present study was to quantify the acute effects of the tourniquet application during TKA on the ( 1 ) concentrations of free/conjugated ubiquitin , ( 2 ) total ubiquitin-protein ligase activity , ( 3 ) proteasome-dependent and ( 4 ) prote 
    Output:
    
agent
The 50 original articles included in this qualitative , systematic review revealed that the recommendations " Tourniquet " of the DGAI published in 2016 are mostly still up to date despite an inhomogeneous study situation .
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Abstract Introduction The clinical success of total knee arthroplasty ( TKA ) depends substantially on the quadriceps muscle function . A frequently applied thigh tourniquet during TKA may induce ischemia related injuries to quadriceps muscle cells . Animal limb muscles subjected to 2–5 h ischemia revealed dysfunctional mitochondria , which in turn compromised the cellular bioenergetics and increased the level of reactive oxygen species . The hypothesis of the present study was that tourniquet application during TKA for 60 min ( min ) affects the amount and function of mitochondria within musculus vastus medialis cells . Material s and methods In a r and omized clinical trial , 10 patients enrolled to undergo primary TKA . The patients were r and omly assigned to the tourniquet ( n = 5 ) or non-tourniquet group ( n = 5 ) after obtaining a written informed consent . For each of the groups , the first muscle biopsy was harvested immediately after performing the surgical approach and the second biopsy exactly 60 min later . All biopsies ( 5 × 5 × 5 mm ) 125 mm3 were harvested from musculus vastus medialis and snap-frozen in liquid nitrogen . The biochemical analysis of the prepared muscle tissues included the measurement of activities of mitochondrial respiratory chain enzyme complexes I – III and citrate synthase . Results Tourniquet-induced 60 min ischemia time did not significantly change the activities of the mitochondrial respiratory chain enzymes complexes I – III of the skeletal muscle cells . The citrate synthase activities found to be not significantly different between both groups . Conclusions The use of tourniquet during TKA within a limited time period of 60 min remained without substantial effects on the amount and function of mitochondria within human skeletal muscle cells Tourniquet pain is a common source of complaint for patients undergoing carpal tunnel decompression and practice varies as to the tourniquet position used . There is little evidence to suggest benefit of one position over another . Our aim was to compare patient and surgeon experience of forearm and arm tourniquets . Following a power calculation , 100 patients undergoing open carpal tunnel decompression under local anaesthetic  were r and omized to either an arm or a forearm tourniquet . Measurements of blood pressure , heart rate and pain were taken at 2.5 min intervals . The operating surgeon also provided a visual analogue scale rating for the extent of bloodless field achieved and for any obstruction caused by the tourniquet . There was no statistically significant inter-group difference in patient pain or physiological response , tourniquet time , bloodless field or length of procedure . The degree of obstruction caused by the tourniquet was significantly higher in the forearm group . Level of Evidence : I. Prospect i ve R and omized Controlled OBJECTIVE Lactate levels are increasingly used to guide resuscitation efforts . Some surgical literature suggests that tourniquet use during phlebotomy falsely elevates results , although studies in healthy volunteers have not demonstrated this . The purpose of this study was to determine in clinical practice whether tourniquet use during the drawing of a lactate results in significantly altered levels compared to the result of a level drawn without a tourniquet . METHODS A prospect i ve cohort study was carried out on emergency department patients whose clinical presentation led a physician to order a lactate level . Written informed consent was obtained from patients or their proxies . Study  lactates  were obtained using a tourniquet during the draw sequence of other laboratory studies . Lactate levels for clinical use were drawn per hospital protocol with no tourniquet . The time of lactate measurements and patient demographic information were recorded . Lactate levels for each patient were compared with the Wilcoxon Rank-Sum Test . RESULTS 40 patients were consented and enrolled . The median clinical lactate level was 1.9 ( interquartile range 1.5 - 2.6 ) , and the median study lactate level was 1.9 ( interquartile range 1.4 - 2.7 ) . There was no difference between paired lactate values ( p=0.95 ) . CONCLUSIONS Tourniquet use appears to have no impact on measured lactate levels . Our findings suggest that current practice s at many institutions regarding lactate collection are likely too stringent and should be changed AIM Thigh pain following tourniquet application is a common complaint in early post operative period following total knee arthroplasty . METHOD Post operative Thigh pain was evaluated in 30 consecutive simultaneous bilateral total knee arthroplasty patients between July 2013 and January 2014 . Patient thigh pain was evaluated with the VAS score . The scale was applied on first , second , third day & second and six weeks after surgery . RESULT There were statistically significant difference in VAS score  in non-tourniquet group on first , second , third post operative day . We did not find statistically significant difference at Second and Six weeks post operatively . CONCLUSION This R and omized trial demonstrates that non-tourniquet use in TKA has less early postoperative pain and leads to better recovery Background In a care under fire situation , a first line response to haemorrhage is to apply a tourniquet and return fire . However , there is little underst and ing of how tourniquets and other haemorrhage control devices impact marksmanship . Methods We compared the impact of the iTClamp and the Combat Application Tourniquet ( CAT ) on marksmanship . Following r and omisation ( iTClamp or CAT ) , trained marksmen fired an AR15 at a scaled silhouette target in prone unsupported position ( shooting task ) . Subjects then attempted to complete the shooting task at 5 , 10 , 15 , 30 and 60 min post-haemorrhage control device application . Results All of the clamp groups ( n=7 ) completed the 60 min shooting task . Five CAT groups ( n=6 ) completed the 5 min shooting task and one completed the 5 and 10 min shooting task before withdrawing . Four CAT groups were stopped due to unsafe h and ling ; two stopped due to pain . When examining hits on mass ( HOM ) for the entire shooting task , there was no significant difference between tourniquet and iTClamp HOM at 5 min ( p=0.18 ) . However , there was a significant difference at 10 min , p=0.003 with tourniquet having significantly fewer HOM ( 1.7±2.7 HOM ) than the iTClamp ( 8.1±3.3 HOM ) group . The total effective HOM for the entire 60 min shooting task showed that the iTClamp group achieved significantly ( p=0.001 ) more HOM than the tourniquet group . Over the entire 60 min shooting exercise , the iTClamp group achieved a median 72 % ( 52/72 ) of available HOM while the tourniquet group obtained 19 % ( 14/72 ) . Conclusions Application of a tourniquet to the dominant arm negates effective return of fire in a care under fire setting after a brief time window . Haemorrhage control devices that preserve function may have a role in care under fire situations , as preserving effectiveness in returning fire has obvious operational merits BACKGROUND The widespread application of tourniquets has reduced battlefield mortality related to extremity exsanguinations . Tourniquet-induced ischemia-reperfusion injury ( I/R ) can contribute to muscle loss . Postischemic conditioning ( PostC ) confers protection against I/R in cardiac muscle and skeletal muscle flaps . The objective of this study was to determine the effect of PostC on extremity muscle viability in an established rat hindlimb tourniquet model . METHODS Rats were r and omly assigned to  PostC-1 , PostC-2 , or no conditioning ischemic groups ( n = 10 per group ) .  Postischemic conditioning , performed immediately after tourniquet release , consisted of four 15-second cycles ( PostC-1 ) or eight 15-second cycles ( PostC-2 ) of alternating occlusion and perfusion of hindlimbs . Twenty-four hours later , muscles were excised . The primary end points were muscle edema and viability ; secondary end points were histologic and markers of oxidative stress . RESULTS Ischemia-reperfusion injury decreased viability in all tourniquet limbs , but viability was not improved in either PostC group . Likewise , I/R result ed in substantial muscle edema that was not reduced by PostC. The predominant histologic feature was necrosis , but no significant differences were found among groups . Markers of oxidative stress were increased similarly among groups after I/R , although myeloperoxidase activity was significantly increased only in the no conditioning ischemic group . A protective effect from PostC was not observed in our model suggesting that PostC was not effective in reducing I/R skeletal muscle injury or any benefits of PostC were not sustained for 24 hours when tissues were assessed . CONCLUSION These negative findings are pertinent as the military investigates different strategies to extend the safe time for tourniquet application OBJECTIVE To determine whether a color-coded tourniquet design ed for public use increases successful tourniquet application by laypeople . METHODS This was a r and omized study conducted on April 25 , 2015 . The study occurred during the Maryl and Day activity at the University of Maryl and in College Park , Maryl and . Investigators recruited participants with posters displayed at major crosswalks around a central testing area . A total of 157 volunteers aged 18 years or older and without prior military service or medical training were enrolled . A participant stood in front of a waist-down mannequin with an isolated leg injury while an investigator read aloud a mass causality scenario . The investigator then asked the participant to apply a tourniquet to the mannequin 's leg . All participants received a 4-step illustrated just-in-time ( JiT ) instruction card design ed to facilitate layperson tourniquet application . Test participants received a color-coded tourniquet design ed for layperson use with instructions printed on the device . Control participants received a black Combat Application Tourniquet ( C-A-T ; Composite Re sources , Rock Hill , SC ) . Participants were r and omized in a 1:1 ratio in blocks of 50 . The primary outcome was the proportion of successful tourniquet applications by those who received color-coded tourniquets compared to those who received black tourniquets . Secondary outcomes included validation of previous data analyzing layperson success with tourniquet application , time for successful placement , reasons for failed applications , and participant self-willingness and comfort using tourniquets . We also analyzed demographic data on the study population and inter-rater reliability regarding the assessment of successful tourniquet application . RESULTS Participants supplied with color-coded tourniquets  successfully placed the device 51.38 % of the time , compared to 44.71 % of the time for controls using a black tourniquet ( risk ratio : 1.15 ; 95 % confidence interval : 0.83 - 1.59 ; P=0.404 ) . Participants  ' self-reported willingness to use a tourniquet rose from 40.8 % before the study to 80.3 % after the study ( P<0.05 ) . CONCLUSIONS The color-coded device did not significantly increase laypeople 's proportion of successful tourniquet applications when compared with a st and ard black device . However , this study reproduced pilot study data showing that laypeople can successfully apply tourniquets about half the time if provided JiT instructions . Age , sex , race , income , and highest level of education were not found to impact one 's ability to properly apply a tourniquet . Laypeople 's willingness to apply tourniquets doubled to 80 % after brief exposure to the device . These results affirm the feasibility of engaging laypeople as immediate lifesavers of trauma victims and justify further efforts to boost rates of proper application BACKGROUND Trauma procedural and management skills are often learned on live tissue . However , there is increasing pressure to use simulators because their fidelity improves and as ethical concerns increase . We r and omized military medical technicians ( medics ) to training on either simulators or live tissue to learn combat casualty care skills to determine if the choice of modality was associated with differences in skill uptake . METHODS Twenty medics were r and omized to trauma training using either simulators or live tissue .  Medics were trained to perform five combat casualty care tasks ( surgical airway , needle decompression , tourniquet application , wound packing , and intraosseous line insertion ) . We measured skill uptake using a structured assessment tool . The medics also completed exit question naires and interviews to determine which modality they preferred . RESULTS We found no difference between groups trained with live tissue versus simulators in how they completed each combat casualty care skill . However , we did find that the modality of assessment affected the assessment score . Finally , we found that medics preferred trauma training on live tissue because of the fidelity of tissue h and ling in live tissue models . However , they also felt that training on simulators also provided additional training value . CONCLUSION We found no difference in performance between medics trained on simulators versus live tissue models . Even so , medics preferred live tissue training over simulation . However , more studies are required , and future studies need to address the measurement bias of measuring outcomes in the same model on which the study participants are trained . LEVEL OF EVIDENCE Therapeutic/care management study , level II Abstract Purpose Recent data suggest diminished post-operative quadriceps muscle strength after tourniquet application  during total knee arthroplasty ( TKA ) . The metabolic effects of the commonly utilized intraoperative tourniquet with consecutive ischaemia on the skeletal muscle cells were unknown . Ubiquitin proteasome system represents one of the main pathways involved in muscle protein breakdown contributing to muscle atrophy . Therefore , the purpose of the present study was to quantify the acute effects of the tourniquet application during TKA on the ( 1 ) concentrations of free/conjugated ubiquitin , ( 2 ) total ubiquitin-protein ligase activity , ( 3 ) proteasome-dependent and ( 4 ) prote 
    Output:
    