Risk factors for failure of limb salvage among veterans with foot ulcers.

BACKGROUND: There is limited available information to guide early discussions involving limb salvage for patients with non-traumatic foot ulcers. We hypothesized patient, wound and treatment factors identifiable at initial operative treatment would be associated with failure of attempted limb salvage. METHODS: We retrospectively assessed United States military veterans treated operatively for non-traumatic foot ulcers at a Veteran's Administration (VA) hospital from 2008 to 2018. Cox proportional hazard analysis assessed for independent associations with eventual above ankle amputation. RESULTS: Limb salvage failed for 52 of 461 patients (11.0%). Univariable associations included initial wound area ≥1 cm (p < .001), immediate TMA (p < .001), diagnosis of PVD (p < .001) or diabetes (p = .005), nonpalpable pulse (p = .006), CKD (p = .023), creatine ≥ 1.5 (p = .004), and HgA1c ≥ 6.2 (p < .001). Independent associations consisted of initial wound area ≥1 cm (HR 6.0, 95% CI 1.4-25.1, p = .014), immediate TMA (HR 3.5, 95% CI 1.9-6.4, p < .001), and PVD (HR 3.5, 95% CI 1.6-7.5, p = .001). When <2 risk factors were present, 99.1% and 96.8% retained their hindfoot at 5 and 10 years, respectively. However, this decreased to 87.3% and 80.1% with two risk factors and fell to 63.3% and 43.3% with three risk factors. CONCLUSION: Failure of limb salvage was increasingly likely as the number of identified independent risk factors increased. These results may assist in prognostication and shared decision making between patients and providers. LEVEL OF EVIDENCE: Prognostic, Level III.

Globalization of Plastic and Reconstructive Surgery: A Continent, Country, and State-Level Analysis of Publications.

Over the past decade, there has been a worldwide increase in plastic and reconstructive surgery research as well as increased interest in global collaboration. However, little is known about who is contributing to this global expansion or the trends of individual countries. The aim of our study was to analyze the output of Plastic and Reconstructive Surgery (PRS) over a decade to elucidate trends in the plastic surgery field. METHODS: The country of origin for all first authors of articles published by PRS from 2010 to 2019 were determined and date extracted using PubMed2XL. The change in frequency of publications over the decade by country, continental contributions, as well as state-level analysis within the United States were analyzed. RESULTS: From 2010 to 2019, there were a total number of 8680 publications with an increase in total articles from 747 to 1049 per year. 54 countries contributed over the decade, with the United States producing the most followed by Italy, China, Canada, and the UK. The top producing states were Texas, New York, California, Massachusetts, and Pennsylvania. CONCLUSIONS: The last decade (2010-2019) saw a large international increase in research, not only with the total number of publications, but also in the diversity of originating country. Our work shows a shift away from a US-focused journal to incorporate more work from our international colleagues, as research is conducted in centers across the globe.

Advanced primary care in San Antonio: linking practice and community strategies to improve health.

Improving health among people living in poverty often transcends narrowly focused illness care. Meaningful success is unlikely without confronting the complex social origins of illness. We describe an emerging community of solution to improve health outcomes for a population of 6000 San Antonio, Texas, residents enrolled in a county health care program. The community of solution comprises a county health system, a family medicine residency program, a metropolitan public health department, and local nonprofit organizations and businesses. Community-based activities responding to the needs of individuals and their neighborhoods are driven by a cohort of promotores (community health workers) whose mission encompasses change at both the individual and community levels. Centered on patients' functional goals, promotores mobilize family and community resources and consider what community-level action will address the social determinants of health. On the clinical side, care teams implement population-based risk assessment and nurse care management with a focus on care transitions as well as other measures to meet the needs of patients with high morbidity and high use of health care. Population-based outcome metrics include reductions in hospitalizations, emergency department and urgent care visits, and the associated charges. Promotores also assess patients' progress along the trajectory of their selected functional goals.