Predictors of outpatient resource utilization following ventral and incisional hernia repair.

INTRODUCTION: Little is known about the predictors of increased ambulatory costs following open ventral and incisional hernia repair (VIHR); however, postoperative complications would be expected to be associated with an increased burden on outpatient resources. The purpose of this study is to evaluate the impact of perioperative factors on outpatient resource utilization following VIHR. METHODS: With IRB approval, the surgery scheduling system was queried to identify all cases of VIHR done at our institution over 3 years. Cases with other procedures done at time of VIHR were excluded. National Surgical Quality Improvement Program clinical data, physician billing data which included market and payor across cases, and medical record review data were combined and evaluated in order to quantify care and predictors of usage during the 6 months postoperatively. RESULTS: Data were analyzed for 308 patients. Median patient age was 52 years (SD = 13.3), and over half were female. The number of outpatient visits to the surgical office varied from 0 to 18 [median = 2; interquartile range (IQR) = 1-3]. CDC Wound Class >1 was associated with increase of mean 1.4 visits (IQR: 0.5-2.3); p = 0.003. Component separation, longer duration of operation, and increased mesh size were also predictive of increased number of office visits (p < 0.01). Postoperative infected seroma/seroma requiring drainage added a mean 2.3 visits (IQR: 1.3-3.3), (p < 0.001); and deep wound infection added a mean 3.9 visits (IQR: 1.9-5.9) (p < 0.001). CONCLUSIONS: Postoperative complications confer a significant burden for patients and to the outpatient surgical office. In an era in which improved quality and cost-efficiency has become imperative, measures to decrease risk of postoperative complications particularly for more complex VIHR would be expected to decrease resource utilization and increase value of care.

Lateral Compression-I Pelvic Ring Injury: Not Benign to the Developing Fetus.

OBJECTIVE: To determine whether certain patterns of pelvic ring injury are associated with more frequent intrauterine fetal demise (IUFD). DESIGN: Retrospective review. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Of 44 pregnant patients with pelvic and/or acetabular fractures, 40 had complete records that allowed determination of fetal viability. χ2 tests were used for categorical variables (Fisher exact tests when expected cell counts were fewer than 5), and t tests were used for continuous variables. MAIN OUTCOME MEASUREMENTS: Fetal or maternal death. RESULTS: Sixteen patients had isolated acetabular fractures, 25 had isolated pelvic ring injuries, and 3 had acetabular fractures with concomitant pelvic ring injuries. Maternal and fetal mortality were 2% and 40%, respectively. No patients with isolated acetabular fractures experienced IUFD, compared with 68% (15/22) of those with isolated pelvic ring injuries (P < 0.0001). Eight (53%) of 15 IUFDs were associated with lateral compression (LC)-I pelvic ring injuries (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen 61-B2). Of the 13 LC-I pelvic ring injuries, 8 (62%) resulted in IUFD. Pelvic ring stability, Young-Burgess classification, and operative treatment were not associated with IUFD. Maternal Glasgow Coma Scale (average 13.2) and Injury Severity Score (average 18.2) at admission were predictive of IUFD. CONCLUSIONS: The most frequent pelvic fractures in gravid trauma patients are LC-I. Although the rate of maternal mortality was low, the risk of IUFD was quite high (40%). LC-I pelvic ring injuries often had catastrophic outcomes, with IUFD in 62% of cases. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Radiation-enhanced therapeutic targeting of galectin-1 enriched malignant stroma in triple negative breast cancer.

Currently there are no FDA approved targeted therapies for Triple Negative Breast Cancer (TNBC). Ongoing clinical trials for TNBC have focused primarily on targeting the epithelial cancer cells. However, targeted delivery of cytotoxic payloads to the non-transformed tumor associated-endothelium can prove to be an alternate approach that is currently unexplored. The present study is supported by recent findings on elevated expression of stromal galectin-1 in clinical samples of TNBC and our ongoing findings on stromal targeting of radiation induced galectin-1 by the anginex-conjugated arsenic-cisplatin loaded liposomes using a novel murine tumor model. We demonstrate inhibition of tumor growth and metastasis in response to the multimodal nanotherapeutic strategy using a TNBC model with orthotopic tumors originating from 3D tumor tissue analogs (TTA) comprised of tumor cells, endothelial cells and fibroblasts. The 'rigorous' combined treatment regimen of radiation and targeted liposomes is also shown to be well tolerated. More importantly, the results presented provide a means to exploit clinically relevant radiation dose for concurrent receptor mediated enhanced delivery of chemotherapy while limiting overall toxicity. The proposed study is significant as it falls in line with developing combinatorial therapeutic approaches for stroma-directed tumor targeting using tumor models that have an appropriate representation of the TNBC microenvironment.

Grandmothers' productivity and the HIV/AIDS pandemic in sub-Saharan Africa.

The human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) pandemic has left large numbers of orphans in sub-Saharan Africa. Botswana has an HIV prevalence rate of approximately 40% in adults. Morbidity and mortality are high, and in a population of a 1.3 million there are nearly 50,000 children who have lost one or both parents to HIV/AIDS. The extended family, particularly grandparents, absorbs much of the childrearing responsibilities. This creates large amounts of additional work for grandmothers especially. The embodied capital model and the grandmother hypothesis are both derived from life history theory within evolutionary ecology, and both predict that one important factor in the evolution of the human extended family structure is that postreproductive individuals such as grandmothers provide substantial support to their grandchildren's survival. Data collected in the pre-pandemic context in a traditional multi-ethnic community in the Okavango Delta of Botswana are analyzed to calculate the amount of work effort provided to a household by women of different ages. Results show that the contributions of older and younger women to the household in term of both productivity and childrearing are qualitatively and quantitatively different. These results indicate that it is unrealistic to expect older women to be able to compensate for the loss of younger women's contributions to the household, and that interventions be specifically designed to support older women based on the type of activities in which they engage that affect child survival, growth, and development.

Trade-offs in skillacquisition and time allocation among juvenile chacma baboons.

We hypothesize that juvenile baboons are less efficient foragers than adult baboons owing to their small size, lower level of knowledge and skill, and/or lesser ability to maintain access to resources. We predict that as resources are more difficult to extract, juvenile baboons will demonstrate lower efficiency than adults will because of their lower levels of experience. In addition, we hypothesize that juvenile baboons will be more likely to allocate foraging time to easier-to-extract resources owing to their greater efficiency in acquiring those resources.We use feeding efficiency and time allocation data collected on a wild, free-ranging, non-provisioned population of chacma baboons (Papio hamadryas ursinus) in the Moremi Wildlife Reserve, Okavango Delta, Botswana to test these hypotheses. The major findings of this study are:1. Juvenile baboons are significantly less efficient foragers than adult baboons primarily for difficult-to-extract resources.We propose that this age-dependent variation in efficiency is due to differences in memory and other cognitive functions related to locating food resources, as is indicated by the greater amount of time juvenile baboons spend searching for food. There is no evidence that smaller body size or competitive disruption influences the differences in return rates found between adult and juvenile baboons in this study.2. An individual baboon's feeding efficiency for a given resource can be used to predict the duration of its foraging bouts for that resource.These results contribute both to our understanding of the ontogeny of behavioral development in nonhuman primates, especially regarding foraging ability, and to current debate within the field of human behavioral ecology regarding the evolution of the juvenile period in primates and humans.

Subsistence ecology and play among the okavango delta peoples of botswana.

Children's play is widely believed by educators and social scientists to have a training function that contributes to psychosocial development as well as the acquisition of skills related to adult competency in task performance. In this paper we examine these assumptions from the perspective of life-history theory using behavioral observation and household economic data collected among children in a community in the Okavango Delta of Botswana where people engage in mixed subsistence regimes of dry farming, foraging, and herding.We hypothesize that if play contributes to adult competency then time allocation to play will decrease as children approach adult levels of competence. This hypothesis generates the following predictions: (1) time allocated to play activities that develop specific productive skills should decline in relation to the proportion of adult competency achieved; (2) children will spend more time in forms of play that are related to skill development in tasks specific to the subsistence ecology in which that child participates or expects to participate; and (3) children will spend more time in forms of play that are related to skill development in tasks clearly related to the gender-specific productive role in the subsistence ecology in which that child participates or expects to participate.We contrast these expectations with the alternative hypothesis that if play is not preparatory for adult competence then time allocated to each play activity should diminish at the same rate. This latter hypothesis generates the following two predictions: (1) time allocation to play should be unaffected by subsistence regime and (2) patterns of time allocation to play should track patterns of growth and energy balance.Results from multiple regression analysis support earlier research in this community showing that trade-offs between immediate productivity and future returns were a primary determinant of children's activity patterns. Children whose labor was in greater demand spent significantly less time playing. In addition, controlling for age and gender, children spent significantly more time in play activities related to tasks specific to their household subsistence economy. These results are consistent with the assertion that play is an important factor in the development of adult competency and highlight the important contributions of an evolutionary ecological perspective in understanding children's developmental trajectories.

Life history and the competitive environment: trajectories of growth, maturation, and reproductive output among chacma baboons.

The social environment is a key feature influencing primate life histories. Chacma baboons (Papio hamadryas ursinus) are a female-bonded species with a strict linear dominance hierarchy. In this species, the allocation of energy to competing demands of growth and reproduction is hypothesized to vary as a function of competitive ability, which in turn increases with social rank. Since growth rate is a major component of life history models, measures of age-specific growth were used to analyze variation in life history traits across social ranks. Weights of 42 immature baboons were obtained without sedation or baiting from a troop of well-habituated chacma baboons in the Okavango Delta, Botswana. Using demographic and weight data from this wild population, five main findings emerged: 1) Weight for age and growth rate of infant and juvenile females are positively associated with maternal rank. 2) Male growth is not influenced by maternal rank. 3) Female growth shows smaller variation across feeding conditions than male growth. 4) Low-ranking adult females continue investment in offspring through prolonged lactation until they reach a weight comparable to that of high-ranking infants. 5) The benefit of rank to reproductive success shown in this study is 0.83 additional offspring. Reproductive span determined predominantly by age at maturation contributes 27-38% to the difference in expected number of offspring by rank, vs. 62-73% due to reproductive rate. These findings have major implications for understanding the role of social environment in phenotypic plasticity of life history traits, and in the evolution of primate life histories.