The effect of κ-carrageenan and ursolic acid on the physicochemical properties of the electrospun nanofibrous mat for biomedical application.

Wound dressing materials such as nanofiber (NF) mats have gained a lot of attention in recent years owing to their wonderful effect on accelerating the healing process and protection of wounds. In this regard, three different types of NF mats were fabricated using pure polyvinylpyrrolidone (PVP), PVP/κ-carrageenan (KG), and ursolic acid (UA) in the optimal PVP/KG ratio by electrospinning method to apply them as wound dressings. The morphology, chemical structure, degradation, porosity, mechanical properties and antioxidant activity of the produced NFs were investigated. Moreover, cell studies (e.g., cell proliferation, adhesion, and migration) and their antibacterial properties were evaluated. Adding KG and UA reduced the mean diameter size of the PVP-based NFs to ∼98 nm in the optimal sample, with defect-free morphology. The PVP/KG/UA 0.25 % exhibited the highest porosity, hydrophilicity, and degradation rate and a wound closure rate of 60 %, 2.5 times higher than that of the control group. Furthermore, this sample's proliferation and antibacterial ability were significantly higher than the other groups. These findings confirmed that the produced UA-loaded NFs have excellent properties as wound dressing.

Soy protein isolate/kappa-carrageenan/cellulose nanofibrils composite film incorporated with zenian essential oil-loaded MOFs for food packaging.

Edible films applied in food packaging must possess excellent inhibitory and mechanical properties. Protein-based films exhibit a high capacity for film formation and offer good gas barrier properties. However, they have weak mechanical and water barrier characteristics. The objective of this research was to develop active composite films based on reinforced soy protein isolate (SPI)/Kappa-carrageenan (K) with varying concentrations of bacterial cellulose nanofibrils (BCN). Increasing the BCN concentration improved the morphological, structural, mechanical, water vapor barrier, and moisture content properties. In comparison to the pure SPI film (S), the film with a high BCN concentration demonstrated a significant decrease in WS (22.98 ± 0.78 %), MC (21.72 ± 0.68 %), WVP (1.22 ± 0.14 g mm-1 S-1 Pa-1 10-10), and EAB (57.77 ± 5.25 %) properties. It should be emphasized that there was no significant alteration in the physicomechanical properties of the optimal film (SKB0.75) containing Zenian-loaded metal-organic frameworks (ZM). However, it substantially enhanced the thermal stability of this film, which can be attributed to the strong interfacial interactions between polymer chains and ZM. Furthermore, the ZM films inhibited the growth of pathogenic bacteria and increased the DPPH antioxidant activity. Thus, SKB0.75-ZM2 films can be utilized as practical components in food packaging.

An Ultrasensitive miRNA-Based Genosensor for Detection of MicroRNA 21 in Gastric Cancer Cells Based on Functional Signal Amplifier and Synthesized Perovskite-Graphene Oxide and AuNPs.

In the present research work, the state-of-art label-free electrochemical genosensing platform was developed based on the hybridization process in the presence of [Fe(CN)6]3-/4- as an efficient redox probe for sensitive recognition of the miRNA-21 in human gastric cell lines samples. To attain this aim, perovskite nanosheets were initially synthesized. Afterward, the obtained compound was combined with the graphene oxide resulting in an effective electrochemical modifier, which was dropped on the surface of the Au electrode. Then, AuNPs (Gold Nano Particles) have been electrochemically-immobilized on perovskite-graphene oxide/Au-modified electrode surface through the chronoamperometry (CA) technique. Finally, a self-assembling monolayer reaction of ss-capture RNA ensued by the thiol group at the end of the probe with AuNPs on the modified electrode surface. miRNA-21 has been cast on the Au electrode surface to apply the hybridization process. To find out the effectiveness of the synthesized modifier agent, the electrochemical behavior of the modified electrode has been analyzed through DPV (differential pulse voltammetry) and CV (cyclic voltammetry) techniques. The prepared biomarker-detection bioassay offers high sensitivity and specificity, good performance, and appropriate precision and accuracy for the highly-sensitive determination of miRNA-21. Different characterization methods have been used, such as XRD, Raman, EDS, and FE-SEM, for morphological characterization and investigation of particle size. Based on optimal conditions, the limit of detection and quantification have been acquired at 2.94 fM and 8.75 fM, respectively. Furthermore, it was possible to achieve a wide linear range which is between 10-14 and 10-7 for miRNA-21. Moreover, the selectivity of the proposed biosensing assay was investigated through its potential in the detection of one, two, and three-base mismatched sequences. Moreover, it was possible to investigate the repeatability and reproducibility of the related bio-assay. To evaluate the hybridization process, it is important that the planned biomarker detection bio-assay could be directly re-used and re-generated.

Ventricular repolarization heterogeneity in patients with COVID-19: Original data, systematic review, and meta-analysis.

BACKGROUND: Coronavirus disease-2019 (COVID-19) has been associated with an increased risk of acute cardiac events. However, the effect of COVID-19 on repolarization heterogeneity is not yet established. In this study, we evaluated electrocardiogram (ECG) markers of repolarization heterogeneity in patients hospitalized with COVID-19. In addition, we performed a systematic review and meta-analysis of the published studies. METHODS: QT dispersion (QTd), the interval between T wave peak to T wave end (TpTe), TpTe/QT (with and without correction), QRS width, and the index of cardio-electrophysiological balance (iCEB) were calculated in 101 hospitalized COVID-19 patients and it was compared with 101 non-COVID-19 matched controls. A systematic review was performed in four databases and meta-analysis was conducted using Stata software. RESULTS: Tp-Te, TpTe/QT, QRS width, and iCEB were significantly increased in COVID-19 patients compared with controls (TpTe = 82.89 vs. 75.33 ms (ms), p-value = .005; TpTe/QT = 0.217 vs. 0.203 ms, p-value = .026). After a meta-analysis of 679 COVID-19 cases and 526 controls from 9 studies, TpTe interval, TpTe/QT, and TpTe/QTc ratios were significantly increased in COVID-19 patients. Meta-regression analysis moderated by age, gender, diabetes mellitus, hypertension, and smoking reduced the heterogeneity. QTd showed no significant correlation with COVID-19. CONCLUSION: COVID-19 adversely influences the ECG markers of transmural heterogeneity of repolarization. Studies evaluating the predictive value of these ECG markers are warranted to determine their clinical utility.

Repolarization disparity as a predictor of response to Head up Tilt-table Test in pediatric syncope.

BACKGROUND: Head up Tilt-table Test (HUTT) is a practical examination of the most common type of pediatrics syncope. The electrocardiographic (ECG) changes during this test, show the autonomic defects that cause neuraly-mediated syncope in response to tilting process. METHODS: All pediatric syncope patients referred to our center in a 1-year period, were included in the study. HUTT was performed and patients were classified into two groups of Negative and Positive HUTT results, and the latter group was subclassified as three subgroups of "vasodepressor", "cardioinhibitory" and "mixed type" responses to HUTT. QT and corrected QT (QTc) dispersion was measured by the baseline standard 12-lead ECG obtained before HUTT. RESULTS: Eighty-six patients with a mean age of 12.19 ± 5.34 were included. Patients with positive HUTT were significantly younger and male gender was more prevalent in this group. Mean QT dispersion was significantly higher in patients with positive HUTT result and also in patients with mixed response to HUTT compared to isolated vasodepressor response. Duration of QTc interval did not change between different study groups. Reciever-Operating-Characteristic (ROC) analysis showed that QT dispersion higher than 32 ms is a significant predictor of positive HUTT result (with 92% sensitivity and 98% specificity) and values higher than 40 ms can predict the mixed type of response to HUTT (with 84% sensitivity and 63% specificity). CONCLUSIONS: Baseline myocardial repolarization disparity significantly correlates with susceptibility to symptomatic vasovagal syncope. This pathology seems to play its role mainly via excessive vagotonic response to sympathetic activation during HUTT process (known as cardioinhibitory response).

Postdischarge Pain Management After Thoracic Surgery: A Patient-Centered Approach.

BACKGROUND: Postoperative analgesia is paramount to recovery after thoracic surgery, and opioids play an invaluable role in this process. However, current 1-size-fits-all prescribing practices produce large quantities of unused opioids, thereby increasing the risk of nonmedical use and overdose. This study hypothesized that patient and perioperative characteristics, including 24-hour before-discharge opioid intake, could inform more appropriate postdischarge prescriptions after thoracic surgery. METHODS: This prospective observational cohort study was conducted in 200 adult thoracic surgical patients. The cohort was divided into 3 groups on the basis of 24-hour before-discharge opioid intake in morphine milligram equivalents (MME): (1) no (0 MME), (2) low (>0 to ≤22.5 MME), or (3) high (>22.5 MME) before-discharge opioid intake. Logistic regression was used to analyze the association of patient and perioperative characteristics with self-reported after-discharge opioid use. RESULTS: Univariate analysis showed that preoperative opioid use, 24-hour before-discharge acetaminophen and gabapentinoid intake, and 24-hour before-discharge opioid intake were associated with higher after-discharge opioid use. Multivariable modeling demonstrated that 24-hour before-discharge opioid intake was most significantly associated with after-discharge opioid use. For example, compared with patients who took high amounts of opioids before discharge, patients who took no opioids before discharge were 99% less likely to take a high amount of opioids after discharge compared with taking none (odds ratio, 0.011; 95% confidence interval, 0.003 to 0.047; P < .001). CONCLUSIONS: Assessment of 24-hour before-discharge opioid intake may inform patient requirements after discharge. Opioid prescriptions after thoracic surgery can thereby be targeted on the basis of anticipated needs.

The Application of Medicare Data for Musculoskeletal Research in the United States: A Systematic Review.

INTRODUCTION: Musculoskeletal conditions disproportionately affect the lives of aging adults. We aimed to examine the literature using Medicare claims data in the United States for musculoskeletal surgical procedures. METHODS: Following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines, we searched the PubMed and Medline databases for peer-reviewed articles published between 1990 and 2015. We included the studies that (1) reported primary Medicare claims data use, (2) involved musculoskeletal surgery, and (3) were original peer-reviewed studies. We abstracted the types of surgical procedure and aims, and evaluated outcomes, and strengths and weaknesses of each included article. We assessed the quality of included articles with Newcastle Ottawa Assessment Scale. RESULTS: The literature search returned 3,233 articles, of which 119 met our inclusion criteria. These studies focused on different outcomes: epidemiology and treatment variation (26), cost of care (15), hospital-level analyses (30), health outcomes (31), the validity and accuracy of Medicare claims data (4), disparities in health care (10), and policy evaluation (3). DISCUSSION: Medicare claims data provide a unique way for researchers to study a nationally representative patient population longitudinally. A significant limitation of using claims data has been a lack of granularity on defining severity of a condition. LEVEL OF EVIDENCE: Therapeutic level III.

Association Between Hearing Aid Use and Health Care Use and Cost Among Older Adults With Hearing Loss.

Importance: Hearing loss (HL) is common among older adults and is associated with poorer health and impeded communication. Hearing aids (HAs), while helpful in addressing some of the outcomes of HL, are not covered by Medicare. Objective: To determine whether HA use is associated with health care costs and utilization in older adults. Design, Setting, and Participants: This retrospective cohort study used nationally representative 2013-2014 Medical Expenditure Panel Survey data to evaluate the use of HAs among 1336 adults aged 65 years or older with HL. An inverse propensity score weighting was applied to adjust for potential selection bias between older adults with and without HAs, all of whom reported having HL. The mean treatment outcomes of HA use on health care utilization and costs were estimated. Exposures: Encounter with the US health care system. Main Outcomes and Measures: (1) Total health care, Medicare, and out-of-pocket spending; (2) any emergency department (ED), inpatient, and office visit; and (3) number of ED visits, nights in hospital, and office visits. Results: Of the 1336 individuals included in the study, 574 (43.0%) were women; mean (SD) age was 77 (7) years. Adults without HAs (n = 734) were less educated, had lower income, and were more likely to be from minority subpopulations. The mean treatment outcomes of using HAs per participant were (1) higher total annual health care spending by $1125 (95% CI, $1114 to $1137) and higher out-of-pocket spending by $325 (95% CI, $322 to $326) but lower Medicare spending by $71 (95% CI, -$81 to -$62); (2) lower probability of any ED visit by 2 percentage points (PPs) (24% vs 26%; 95% CI, -2% to -2%) and lower probability of any hospitalization by 2 PPs (20% vs 22%; 95% CI, -3% to -1%) but higher probability of any office visit by 4 PPs (96% vs 92%; 95% CI, 4% to 4%); and (3) 1.40 more office visits (95% CI, 1.39 to 1.41) but 0.46 (5%) fewer number of hospital nights (95% CI, -0.47 to -0.44), with no association with the number of ED visits, if any (95% CI, 0.01 to 0). Conclusions and Relevance: This study demonstrates the beneficial outcomes of use of HAs in reducing the probability of any ED visits and any hospitalizations and in reducing the number of nights in the hospital. Although use of HAs reduced total Medicare costs, it significantly increased total and out-of-pocket health care spending. This information may have implications for Medicare regarding covering HAs for patients with HL.

Association of Interleukin-6 and Interleukin-1 Family Gene Polymorphisms in Autoimmune Hepatitis.

INTRODUCTION AND AIM: Autoimmune hepatitis (AIH) is an immune-mediated destruction of liver cells, in recognition of interface hepatitis, seropositivity for autoantibodies, and interface hepatitis in histology sections. Hepatocyte destruction in AIH is the direct result of CD4+ T-cell destruction. Yet, Th17 mediated immune attach and a diversity of cytokine networks, including pro-inflammatory cytokines such as Interleukin 1 (IL-1) and Interleukin 6 (IL-6), set the stage for the destructive liver damage. MATERIAL AND METHOD: Peripheral blood samples from 57 patients, with AIH, recruited from referrals to the main pediatric hospital in Tehran. Single nucleotide polymorphisms for the following cytokines genes, were evaluated through, polymerase chain reaction with sequencespecific primers (PCR-SSP) assay: IL-1a (C/T -889), IL-1α (C/T -511), IL-1ß (C/T +3962), IL-1 receptor (IL-1R; C/T Pst-I 1970), IL-1RA (C/T Mspa-I 11100), and IL-6 (C/G -174 and A/G nt565). RESULTS: Significant higher frequency of genotype AA was detected in patients in IL-6 at position nt565 (15.8% in AIH patients vs. 2.9% in controls, p = 0.003). The haplotype GA of IL-6 at -174 and nt565, was significantly overrepresented in the AIH group, compared to (20.9% of AIH vs. 1.4% in controls p < 0.0001). CONCLUSION: Results of our study, indicate significant deviation toward high yield IL-6 polymorphisms, in AIH patients. These data could bring new insights in pathophysiology of disease, which could contribute to developing novel treatments for AIH.

Association of High-Volume Surgeons Working in High-Volume Hospitals with Cost of Free Flap Surgeries.

BACKGROUND: We examined the associations of surgeon and hospital volume with total cost, length of stay (LOS), and cost per day for free tissue transfer (FTT) surgeries. Evidence demonstrates a higher likelihood of success for FTT in higher volume hospitals. Little, however, is known about volume-outcome associations for surgical costs and LOS. We hypothesized that higher provider volume is associated with lower cost and shorter LOS. METHODS: Using Taiwan's national data (2001-2012), we conducted a retrospective cohort study of all adults 18-64 years of age who underwent FTT during the study period. We used hierarchical regression modeling for our analyses. Our 3 outcome variables were total cost of FTT surgery, LOS in hospital, and cost per day. RESULTS: Except for functional muscle flap, in which LOS was 12 days shorter in high-volume compared with low-volume hospitals (P = 0.017), no association between hospital volume and LOS was found. Contrary to our hypothesis, our results for all FTT cases demonstrate positive associations of medium-volume hospitals (OR = 1.31; CI, 1.11-1.55) and high-volume surgeons (OR = 1.16; CI,1.03-1.32) with total cost and cost per day, respectively. The interactions of hospital volume and surgeon volume show that in medium- and high-volume hospitals, surgeons with the highest volume had the lowest predicted cost per day among hospitals in that category; but all differences in cost were small. CONCLUSIONS: There were no substantial variations based on different hospital or surgeon volume in LOS, total cost, or cost per day for FTT operations performed in Taiwan.

Associations of Surgeon and Hospital Volumes with Outcome for Free Tissue Transfer by Using the National Taiwan Population Health Care Data from 2001 to 2012.

BACKGROUND: Greater hospital case volumes are associated with improved outcomes for high-risk procedures. The hospital-outcome association for complex but low-mortality procedures and the association between surgeon versus hospital case volume and surgical outcomes have been less explored. The authors examined the association between surgeon and hospital volume and the success for free tissue transfer (free flap) surgery. The authors hypothesized that there would be positive associations between hospital and surgeon volume and the success of free flap surgery. METHODS: The study design was a cross-sectional analysis of adults aged 18 to 64 years who underwent free flap surgery. The authors used 100 percent of all free flap operations between 2001 and 2012 using Taiwan's national data that cover the entire population of 23 million in the country. The authors applied hierarchical regression modeling to analyze volume-outcome associations. RESULTS: The association between hospital volume and free flap success was small but positive (OR, 1.007; 95 percent CI, 1.00 to 1.01). For surgeons, their years of experience had a positive association with success of the operation (OR, 1.04; 95 percent CI, 1.02 to 1.06) rather than their annual case volume. Compared with low-volume surgeons (<11 annual cases) working in low-volume hospitals (<95 annual cases), high-volume surgeons (>25 annual cases) working in high-volume hospitals (>156 annual cases) showed greater odds of operation success (OR, 2.97; 95 percent CI, 1.21 to 7.29). CONCLUSIONS: Higher volume hospitals and more experienced surgeons, regardless of their annual volume, showed better outcomes. Increasing demand for high-quality care and Taiwan's national policies toward centralization of complex surgical procedures have increased competition among hospitals. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Associations of Hospital Volume, Surgeon Volume, and Surgeon Experience with Complications and 30-Day Rehospitalization after Free Tissue Transfer: A National Population Study.

BACKGROUND: Greater provider volume is associated with better outcomes. There is, however, a paucity of evidence on volume-outcome associations for surgical complications and 30-day all-cause rehospitalization after free tissue transfer or free flap surgery. Surgical complications and frequent rehospitalization are important quality indicators that substantially hinder appropriate health care spending. The authors hypothesized that increased provider volume and surgeon experience are associated with lower complication and hospital readmission rates. METHODS: The authors conducted a retrospective cohort study of adults aged 18 to 64 years who underwent free tissue transfer. They examined 100 percent of all free tissue transfers between 2001 and 2012 using Taiwan's national data, and used regression modeling to examine associations between volume and outcome. All models were adjusted for patient, surgeon, and hospital characteristics. RESULTS: Seventeen percent of free tissue transfer operations (4201 of 25,327) had complications. Infection was the most prevalent after free tissue transfer (70 percent), and the 30-day rehospitalization rate was approximately 20 percent. Hospital volume was associated with a small decrease in complications (OR, 0.99; 95 percent CI, 0.99 to 0.99; p < 0.01). For surgeons, years of experience and not annual case volume decreased surgical complications (OR, 0.98; 95 percent CI, 0.97 to 0.99; p = 0.01). The authors did not find any association between hospital or surgeon volume, or surgeon's years of experience and 30-day rehospitalization. CONCLUSIONS: Higher-volume hospitals and more experienced surgeons were shown to have a lower likelihood of postsurgery complications. Hospital process and structure affect outcomes and reduce surgical complications. Reducing 30-day rehospitalization may require payment reform, as it demands coordinated care before and after hospital discharge. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Association of a Policy Mandating Physician-Patient Communication With Racial/Ethnic Disparities in Postmastectomy Breast Reconstruction.

IMPORTANCE: With the stabilization of breast cancer incidence and substantial improvement in survival, more attention has focused on postmastectomy breast reconstruction (PBR). Despite its demonstrated benefits, wide disparities in the use of PBR remain. Physician-patient communication has an important role in disparities in health care, especially for elective surgical procedures. Recognizing this, the State of New York enacted Public Health Law (NY PBH Law) 2803-o in 2011 mandating that physicians communicate about reconstructive surgery with patients undergoing mastectomy. OBJECTIVE: To evaluate whether mandated physician-patient communication is associated with reduced racial/ethnic disparities in immediate PBR (IPBR). DESIGN, SETTING, AND PARTICIPANTS: This retrospective study used state inpatient data from January 1, 2008, through December 31, 2011, in New York and California to evaluate a final sample of 42 346 women aged 20 to 70 years, including 19 364 from New York (treatment group) and 22 982 from California (comparison group). The primary hypothesis tested the effect of the New York law on racial/ethnic disparities, using California as a comparator. The National Academy of Medicine's (formerly Institute of Medicine) definition of a disparity was applied, and a difference-in-differences method (before-and-after comparison design) was used to evaluate the association of NY PBH Law 2803-o mandating physician-patient communication with disparities in IPBR. Data were analyzed from July 1, 2016, to February 24, 2017. EXPOSURES: New York PBH Law 2803-o was implemented on January 1, 2011. The preexposure period included January 1, 2008, through December 31, 2010 (3 years); the postexposure period, January 1 through December 31, 2011 (1 year). MAIN OUTCOMES AND MEASURES: The primary outcome was use of IPBR among white, African American, Hispanic, and other minority groups before and after the implementation of NY PBH Law 2803-o. RESULTS: Among the 42 346 women (mean [SD] age, 53 [10] years), 65.3% (27 654) were white, 12.7% (5365) were Hispanic, 9.4% (3976) were African American, and 12.6% (5351) were other minorities. The new legislation was not associated with the overall IPBR rate or disparity in IPBR between whites and African Americans (reduction of 1 percentage point; 95% CI, -0.02 to 0.04), but it was associated with a reduction in disparities in IPBR between Hispanic and white patients by 9 (95% CI, 0.06-0.11) percentage points and between other minorities and white patients by 13 (95% CI, 0.11-0.16) percentage points. CONCLUSIONS AND RELEVANCE: Physician-patient communication may help to address inequity in the use of elective surgical procedures, such as IPBR. However, lack of patient trust and/or effective physician-patient communication may reduce the potential effect of mandatory communication for some subpopulations, including African American individuals.

Annual Hospital Volume and Success of Digital Replantation.

BACKGROUND: Digital replantation attempt and success rates have been declining in the United States. Regionalization of digit replantation has been proposed as a solution to improve both attempt and success rates of these procedures. There is limited information about which criteria could establish a hospital as a center specialized for digit replantation. The authors analyzed hospital replantation volume and patient factors associated with successful thumb/finger replantation. METHODS: A retrospective study using data from the 2008 to 2012 State Inpatient Databases of the Health Care Cost and Utilization Project from five states (New York, California, North Carolina, Utah, and Florida) was performed. The generalized estimating equation method was used to examine the association between patient characteristics and hospital volume and success of thumb/finger replantation. A receiver operating characteristic curve and Youden's J statistic were used to determine annual hospital replantation volume cutoff levels for success rates. RESULTS: There were 3417 digit amputation injuries, with 631 replantation attempts (18 percent) and with an overall thumb/finger replantation success rate of 70 percent. The hospital annual replantation volume increased the odds of success (OR, 1.06; 95 percent CI, 1.02 to 1.10). The annual hospital volume of three replantations was needed to achieve a success rate of 70 percent. CONCLUSIONS: Practice patterns demonstrate that hospitals with higher annual volume have greater success. Identifying high-volume centers and regionalization of digit replantation should be considered a priority. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Evidence-Based Practice in the Surgical Treatment of Thumb Carpometacarpal Joint Arthritis.

PURPOSE: Thumb carpometacarpal (CMC) arthritis contributes considerably to functional disability in the aging adult United States (US) population. Owing to the increasing growth in this segment of our population, its burden on health care resources will increase in the future. Variations exist in the degree of complexity and cost among different surgical treatments. We examined the national trends of the surgical treatment of thumb CMC arthritis and hypothesized that current practice patterns are not supported by evidence favoring the simpler trapeziectomy-only procedure. METHODS: Using a random 5%, nationally representative, sample of Medicare fee-for-service beneficiaries diagnosed with thumb CMC arthritis between 2001 and 2010, we used a multinomial logistic regression model to assess the association between patients' characteristics and the surgical treatment. Furthermore, we used surgeons' unique identifiers to examine how their practice preferences have changed over time. RESULTS: Our findings demonstrated an increasing trend in the utilization of trapeziectomy with ligament reconstruction and tendon interposition (LRTI) from 84% in 2001 to 90% in 2010. Ninety-five percent of surgeons performed only 1 type of surgical procedure, and among those, 93% of surgeons performed only trapeziectomy with LRTI. Compared with 2001, the odds of a patient undergoing thumb CMC arthrodesis or prosthetic arthroplasty slightly increased between 2007 and 2010. CONCLUSIONS: The majority of hand surgeons in the US use trapeziectomy with LRTI as the surgical treatment of choice for thumb CMC arthritis. Although clinical trials from the United Kingdom support the use of the less complex trapeziectomy-only procedure, US surgeons are still reticent to change their practice, which favors LRTI. National comparative studies are still needed to examine the effectiveness of various surgical options for the treatment of thumb CMC joint arthritis. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Emergency Department Wait Time and Treatment of Traumatic Digit Amputation: Do Race and Insurance Matter?

BACKGROUND: Little is known about the association between the quality of trauma care and management of nonfatal injuries. The authors used emergency department wait times as a proxy for hospital structure, process, and availability of on-call surgeons with microsurgical skills. They evaluated the association between average hospital emergency department wait times and likelihood of undergoing digit replantation for patients with traumatic amputation digit injuries. The authors hypothesized that hospitals with shorter emergency department wait times were associated with higher odds of replantation. METHODS: Using the 2007 to 2012 National Trauma Data Bank, the authors' final sample included 12,126 patients. Regression modeling was used to first determine factors that were associated with longer emergency department wait times among patients with digit amputation injuries. Second, the authors examined the association between emergency department wait times for this population at a hospital level and replantation after all types of digit amputation and after complicated thumb amputation injuries only. RESULTS: For patients with simple and complicated thumb amputation injuries, and patients with complicated thumb amputation injuries only, longer emergency department wait times were associated with lower odds of replantation. In addition, being minority and having no insurance were associated with longer emergency department wait times; teaching hospitals were associated with shorter emergency department wait times; and finally, for patients with complicated thumb amputation injuries only, there was no association between patients' minority or insurance status and replantation. CONCLUSION: Variation in emergency department wait time and its effects on treatment of traumatic digit amputation may reflect maldistribution of hand or plastic surgeons with the required microsurgical skills among trauma centers across the United States. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Population-Based Study of Replantation After Traumatic Thumb Amputation, 2007-2012.

PURPOSE: The recommended surgical treatment after thumb amputation is replantation. In the United States, fewer than 40% of thumb amputation injuries are replanted, and little is known about factors associated with the probability of replantation. We aimed to investigate recent trends and examine patient and hospital characteristics that are associated with increased probability of attempted thumb replantation. We hypothesized that higher-volume teaching hospitals and level-I trauma centers attempted more replantations. METHODS: We used 2007-2012 data from the National Trauma Data Bank. Our final sample included 2,206 traumatic thumb amputation patients treated in 1 of 365 centers during the study period. First, we used a 2-level hierarchical logistic model to estimate the odds of replantation. In addition, we used a treatment effect estimation method, with the inverse propensity score weighting to examine the difference in thumb replantation if the only variation among patients was their presumptive payer. RESULTS: There was a higher probability of attempted replantation at teaching hospitals than nonteaching hospitals (odds ratio [OR], 1.40). Patients were less likely to undergo replantation at a level II (OR, 0.53) or a level III (OR, 0.33) trauma center. The uninsured were less likely to undergo replantation (OR, 0.61) than those with private insurance. CONCLUSIONS: Having insurance coverage and being treated in a high-volume, teaching, level-I trauma hospital increased the odds of replantation after traumatic thumb amputation. Regionalization may lead to a higher number of indicated cases of replantation actually being attempted. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Effect of Hospital Volume on Success of Thumb Replantation.

PURPOSE: Hospital volume-outcome association has been examined for many high-risk surgical procedures. Little is known about this association for thumb replantation, a complex but essential surgical procedure to restore hand function. We aimed to determine patient and hospital characteristics that are associated with increased probability of replanted thumb survival and to examine volume-outcome association among hospitals that performed thumb replantation. METHODS: We used data from 2008 to 2012 from the National Trauma Data Bank. Our sample included 773 patients who underwent thumb replantation procedures in 1 of 180 hospitals during the study period. We used patient-level logistic models to examine the association between a hospital's annual thumb replantation volume and the probability of survival for the replanted thumb. RESULTS: Patients with drug/alcohol abuse record, and higher numbers of comorbid conditions had lower odds of replant success. Treatment in teaching hospitals and hospitals with a higher volume of thumb replantation increased the odds of replant survival. The risk-adjusted replantation success rate in high-volume hospitals was 12% higher than in low-volume hospitals. CONCLUSIONS: Regionalization of digit replantation procedures to high-volume centers can achieve the highest rate of successful revascularization. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis II.

Medicare Spending and Evidence-Based Approach in Surgical Treatment of Thumb Carpometacarpal Joint Arthritis: 2001 to 2010.

BACKGROUND: Despite equivalent outcomes among surgical treatments of thumb carpometacarpal arthritis, little is known about the variation in spending. Because of its complexities, the authors hypothesized that trapeziectomy with ligament reconstruction and tendon interposition incurs the greatest cost to Medicare compared with other surgical procedures. METHODS: Using a random 5 percent sample of Medicare beneficiaries diagnosed with thumb carpometacarpal joint arthritis, the authors examined total and out-of-pocket spending for 3530 patients who underwent a surgical treatment between 2001 and 2010. The authors used generalized linear regression models, controlling for patient characteristics and place of surgery, to examine variations in spending. RESULTS: Eighty-nine percent of patients who underwent surgery received trapeziectomy with ligament reconstruction and tendon interposition, with total and out-of-pocket spending of $2576 (95 percent CI, $2333 to $2843; p < 0.001) and $436 (95 percent CI, $429 to $531; p < 0.001), respectively. Simple complete trapeziectomy was the least expensive procedure, performed in 5 percent of patients, with total and out-of-pocket spending of $1268 (95 percent CI, $1089 to $1476; p < 0.001) and $236 (95 percent CI, $180 to $258; p < 0.001), respectively. Because of increasingly higher facility costs, performing the same procedure in a hospital outpatient setting compared with an ambulatory center would increase Medicare spending by more than two-fold (p < 0.001). CONCLUSIONS: With a consistent rise in health care spending, adherence to an evidence-based approach in medicine is more important than ever. Most surgeons continue to perform trapeziectomy with ligament reconstruction and tendon interposition, the most expensive surgical option. Medicare could potentially save $7.4 million annually if simple complete trapeziectomy was the procedure of choice.

A Systematic Review of Economic Analysis of Surgical Mission Trips Using the World Health Organization Criteria.

BACKGROUND: Although the World Health Organization (WHO) has developed tools to standardize economic evaluations of global health interventions, little is known about the cost-effectiveness of surgical mission trips and their economic values. Our objective was to systematically evaluate the current literature on surgical volunteering trips to measure their adherence to WHO CHOosing Interventions that are cost-effective (WHO-CHOICE). We hypothesized that the majority of studies use some type of cost-effectiveness analysis that do not adhere to these standards. METHODS: A systematic review of Pubmed, Medline, and Embase databases was performed in accordance with PRISMA guidelines, with inclusion criteria set a priori. Of the 908 publications screened, 72 were selected for full text review; 17 met inclusion criteria. RESULTS: Only 17 out of 72 studies reported some type of economic analysis. We categorized the studies into service, educational, and combination (service and educational) surgical trips. Although seven of the service studies calculated the cost per disability-adjusted life year averted, the results were not based on WHO-CHOICE standards to facilitate comparisons among alternative options. Furthermore, none of the three educational trips calculated the value of the education provided, but only published cost estimates of the resources used during the trip. CONCLUSIONS: Although a few studies performed some type of economic analysis, owing to their non-adherence to WHO-CHOICE standards, the results were not comparable to other studies. International surgical trips are expensive. To improve the efficacy and optimal use of limited resources, studies on surgical trips should follow the guidelines set by the WHO-CHOICE.