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1.
Surg Open Sci ; 7: 12-17, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-34778738

RESUMO

Background: Coronary artery bypass grafting 30-day unplanned readmission is a focus for the CMS Hospital Readmissions Reduction Program. Awareness of the critical elements of the care delivery environment, including hospital infrastructure and patient clinical profiles that predispose toward readmission, is essential to proactively decrease readmissions. Methods: The Healthcare Cost and Utilization Project-State Inpatient Database, American Hospital Association Annual Health Survey Database, and Healthcare Information Management Systems Society data sets were merged to create a single data set of patient- and hospital-level data from 8 states. Isolated coronary artery bypass grafting procedures were queried for all-cause 30-day readmission, and backwards stepwise logistic regression was performed. Readmission rate was then used to categorize hospitals into quartiles, and analysis focused on the hospitals with the lowest (Q1) and highest (Q4) readmission rates. Univariate analysis was performed comparing Q1 and Q4 hospitals. Results: A total of 150,215 patients underwent isolated coronary artery bypass grafting with 23,244 (15.5%) readmitted patients among 903 hospitals. Model area under the curve was 0.709 (95% confidence interval, 0.702-0.716), with the top 3 readmission determinants related to discharge disposition. Compared to Q1, Q4 patients more often were female, were > 70 years of age, and had Medicare as a primary payor (P < .001). Low readmission rate hospitals were characterized by higher costs; not-for-profit status; having Joint Commission accreditation; and higher total admissions, operative volume, hospital/ICU beds, full-time physicians, nurses, and ancillary personnel (P < .001). Conclusion: Readmission after coronary artery bypass grafting is strongly influenced by discharge disposition. However, hospital factors such as scale, personnel, and ownership structure are significant contributors to readmission. Focus beyond patient factors to include the entire continuum of care is required to enhance outcomes, of which readmission is one surrogate measure.

2.
Clin Psychol Rev ; 90: 102098, 2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-34763126

RESUMO

Advancements in the understanding and prevention of self-injurious thoughts and behaviors (SITBs) are urgently needed. Intensive longitudinal data collection methods-such as ecological momentary assessment-capture fine-grained, "real-world" information about SITBs as they occur and thus have the potential to narrow this gap. However, collecting real-time data on SITBs presents complex ethical and practical considerations, including about whether and how to monitor and respond to incoming information about SITBs from suicidal or self-injuring individuals during the study. We conducted a systematic review of protocols for monitoring and responding to incoming data in previous and ongoing intensive longitudinal studies of SITBs. Across the 61 included unique studies/samples, there was no clear most common approach to managing these ethical and safety considerations. For example, studies were fairly evenly split between either using automated notifications triggered by specific survey responses (e.g., indicating current suicide risk) or monitoring and intervening upon (generally with a phone-based risk assessment) incoming responses (36%), using both automated notifications and monitoring/intervening (35%), or neither using automated notifications nor monitoring/intervening (29%). Certain study characteristics appeared to influence the safety practices used. Future research that systematically evaluates optimal, feasible strategies for managing risk in real-time monitoring research on SITBs is needed.

3.
Am J Surg ; 2021 Nov 19.
Artigo em Inglês | MEDLINE | ID: mdl-34815028

RESUMO

BACKGROUND: We evaluate the association between attending surgeon involvement and clinical outcome in elective inguinal hernia repairs performed by residents. METHODS: Patients undergoing initial elective unilateral inguinal hernia repair between 2004 and 2019 were identified using the Veterans Administration Surgical Quality Improvement Program Database. The level of attending surgeon involvement was categorized as active (attending scrubbed [AS]) or passive (supervising the resident's performance but not scrubbed [ANS]). AS and ANS herniorrhaphies were 1:1 propensity matched for patient demographics, comorbidities, surgical approach, resident postgraduate level, and year of repair. Rates of complication and recurrence for matched cohorts were compared by standard methods. RESULTS: 30,784 patients met inclusion criteria. 5136 (17%) repairs were performed without the attending scrubbed. On comparison of matched-cohorts, overall complication rates (1.7% vs 1.2%, p = 0.07) and rates of recurrence (1.9% vs 1.4%, p = 0.041) for patients undergoing herniorrhaphy AS were statistically similar to those performed ANS. CONCLUSION: Supervised independence in elective inguinal hernia repair performed by surgical residents is not associated with inferior clinical outcomes.

4.
J Eat Disord ; 9(1): 149, 2021 Nov 08.
Artigo em Inglês | MEDLINE | ID: mdl-34749802

RESUMO

BACKGROUND: A common complaint of individuals suffering from mental health conditions is feeling invalidated or misunderstood by care providers. This is notable, given that non-collaborative care has been linked to poor engagement, low motivation and treatment non-adherence. This study examined how receiving validation from care providers is experienced by individuals who have an eating disorder (ED) and the impact of receiving validation on the recovery journey. METHODS: Eighteen individuals who had an eating disorder for an average duration of 19.1 years (two identifying as male, 16 identifying as female), participated in semi-structured interviews on barriers and facilitators to self-compassion. Seven were fully recovered, and 11 were currently participating in recovery-focused residential treatment. Thematic analysis focused on the meaning and impact of receiving validation to participants. RESULTS: Five care provider actions were identified: (i) making time and space for me, (ii) offering a compassionate perspective, (iii) understanding and recognizing my treatment needs, (iv) showing me I can do this, and (v) walking the runway. These were associated with four key experiences (feeling trust, cared for, empowered, and inspired), that participants described as supportive of their recovery. CONCLUSIONS: This research provides insight into patient perspectives of validation and strategies care providers can use, such as compassionate reframing of difficult life experiences, matching interventions to patient readiness, and modeling vulnerability.

5.
FEMS Microbiol Ecol ; 2021 Nov 17.
Artigo em Inglês | MEDLINE | ID: mdl-34791198

RESUMO

Variation in dispersal ability among taxa affects community assembly and biodiversity maintenance within metacommunities. Although fungi and bacteria frequently coexist, their relative dispersal abilities are poorly understood. Nectar-inhabiting microbial communities affect plant reproduction and pollinator behavior, and are excellent models for studying dispersal of bacteria and fungi in a metacommunity framework. Here, we assay dispersal ability of common nectar bacteria and fungi in an insect-based dispersal experiment. We then compare these results to the incidence and abundance of culturable flower-inhabiting bacteria and fungi within naturally occurring flowers across two coflowering communities in California across two flowering seasons. Our microbial dispersal experiment demonstrates that bacteria disperse via thrips among artificial habitat patches more readily than fungi. In the field, incidence and abundance of culturable bacteria and fungi were positively correlated but bacteria were much more widespread. These patterns suggest shared dispersal routes or habitat requirements among culturable bacteria and fungi, but differences in dispersal or colonization frequency by thrips, common flower visitors. The finding that culturable bacteria are more common among nectar sampled here, in part due to superior thrips-mediated dispersal, may have relevance for microbial life-history, community assembly of microbes and plant-pollinator interactions.

7.
Plant Dis ; 2021 Nov 09.
Artigo em Inglês | MEDLINE | ID: mdl-34752125

RESUMO

A new and devastating disease, rapid ohia death (ROD), in Hawaii led to a state quarantine that regulates inter-island transport of ohia wood and plant material to prevent spread of the causal pathogens. Heat treatments of ohia logs in commercial trade were considered for phytosanitary treatment. Vacuum steam (VS) was evaluated for its ability to eradicate the pathogens, Ceratocystis lukuohia and/or C. huliohia, in main stem logs from ROD-affected forest trees. Replicate loads of three de-barked logs (24 to 43 cm diameter; 1.7 to 2.0 m long) were VS-treated at 56° C for 30 min (5 loads) or 60° C for 60 min (4 loads) at a sapwood depth equal to 70% of log radius. Percent isolation of Ceratocystis from VS and ambient temperature logs prior to treatment and summarized by source tree ranged from 12 to 66% and 6 to 31% based on carrot baiting assays of tissue taken from outer and inner sapwood, respectively. No viable Ceratocystis was detected in either sapwood locations for the 60° C/ 60 min schedule or for the inner locations for the 56° C/ 30 min schedule following treatment. Only one subsample (0.48%, n=208) of the latter schedule treatment yielded Ceratocystis. Time required for treatment ranged from 7.4 to 15 h for the 56° C/ 30 min schedule and from 8.6 to 19.2 h for the 60° C/ 60 min schedule. These results demonstrate VS is an effective and efficient method for treating large diameter ohia logs that mill owners and regulatory plant pathologists may consider for use in Hawaii.

8.
J Surg Oncol ; 2021 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-34617590

RESUMO

BACKGROUND AND OBJECTIVES: Few empiric studies evaluate the effects of regionalization on pancreatic cancer care. METHODS: We queried the National Cancer Database to identify patients undergoing pancreaticoduodenectomy for clinical stage I/II pancreatic adenocarcinoma between 2006 and 2015. Facilities were categorized by annual pancreatectomy volume. Textbook oncologic outcome was defined as a margin negative resection, appropriate lymph node assessment, no prolonged hospitalization, no 30-day readmission, no 90-day mortality, and timely receipt of adjuvant chemotherapy. Multivariable regression adjusted for comorbid disease, pathologic stage, and facility characteristics was used to evaluate the relationship between facility volume and textbook outcome. RESULTS: Sixteen thousand six hundred and two patients underwent pancreaticoduodenectomy; 3566 (21.5%) had a textbook outcome. Operations performed at high volume centers increased each year (45.8% in 2006 to 64.2% in 2015, p < 0.001) as did textbook outcome rates (14.3%-26.2%, p < 0.001). Surgical volume was associated with textbook outcome. High volume centers demonstrated higher unadjusted rates of textbook outcome (25.4% vs. 11.8% p < 0.01) and increased adjusted odds of textbook outcome relative to low volume centers (odds ratio: 2.39, [2.02, 2.85], p < 0.001). Textbook outcome was associated with improved overall survival independent of volume. CONCLUSIONS: Regionalization of care for pancreaticoduodenectomy to high volume centers is ongoing and is associated with improved quality of care.

9.
Biol Bull ; 241(2): 140-157, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34706206

RESUMO

AbstractA combination of receptors, co-receptors, and secreted Wnt modulators form protein complexes at the cell surface that activate one or more of the three different Wnt signaling pathways (Wnt/ß-catenin, Wnt/JNK, and Wnt/Ca2+). Two or more of these pathways are often active in the same cellular territories, forming Wnt signaling networks; however, the molecular mechanisms necessary to integrate information from these pathways in these situations are unclear in any in vivo model system. Recent studies have implicated two Wnt binding receptor tyrosine kinases, receptor tyrosine kinase-like orphan receptor (Ror) and related-to-receptor tyrosine kinase (Ryk), in the regulation of canonical and non-canonical Wnt signaling pathways, depending on the context; however, the spatiotemporal expression of these genes in relation to Wnt signaling components has not been well characterized in most deuterostome model systems. Here we use a combination of phylogenetic and spatiotemporal gene expression analyses to characterize Ror and Ryk orthologs in sea urchin embryos. Our phylogenetic analysis indicates that both ror1/2 and ryk originated as single genes from the metazoan ancestor. Expression analyses indicate that ror1/2 and ryk are expressed in the same domains of many Wnt ligands and Frizzled receptors essential for the specification and patterning of germ layers along the early anterior-posterior axis. In addition, both genes are co-expressed with Wnt signaling components in the gut, ventral ectoderm, and anterior neuroectoderm territories later in development. Together, our results indicate that Ror and Ryk have a complex evolutionary history and that their spatiotemporal expression suggests that they could contribute to the complexity of Wnt signaling in early sea urchin embryogenesis.

10.
Int Rev Neurobiol ; 160: 305-340, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34696877

RESUMO

Alcohol drinking is often initiated during adolescence, and this frequently escalates to binge drinking. As adolescence is also a period of dynamic neurodevelopment, preclinical evidence has highlighted that some of the consequences of binge drinking can be long lasting with deficits persisting into adulthood in a variety of cognitive-behavioral tasks. However, while the majority of preclinical work to date has been performed in male rodents, the rapid increase in binge drinking in adolescent female humans has re-emphasized the importance of addressing alcohol effects in the context of sex as a biological variable. Here we review several of the consequences of adolescent ethanol exposure in light of sex as a critical biological variable. While some alcohol-induced outcomes, such as non-social approach/avoidance behavior and sleep disruption, are generally consistent across sex, others are variable across sex, such as alcohol drinking, sensitivity to ethanol, social anxiety-like behavior, and induction of proinflammatory markers.

11.
Surg Open Sci ; 6: 15-20, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34409279

RESUMO

Background: Achieving microscopically negative (R0) surgical margins in gallbladder cancer often requires a partial hepatectomy with associated risk of morbidity and potential to delay adjuvant therapy. Prior studies on the importance of margin status in resectable gall bladder cancer include small numbers of patients with positive (R1) resection margins and are underpowered. Methods: We queried the National Cancer Database to identify patients undergoing resection of gallbladder adenocarcinoma between 2004 and 2015. Patients presenting with metastatic disease, those who received neoadjuvant therapy, and those with fewer than 3 lymph nodes assessed were excluded. 1:1 propensity score matching was used to develop cohorts undergoing either R0 or R1 resection, matched for demographic, pathologic, and facility characteristics. Kaplan-Meier analysis was used to assess the association between margin status and overall survival. Results: A total of 1,439 patients met inclusion criteria; 1,285 underwent R0 and 154 underwent R1 resection. On Kaplan-Meier analysis of propensity-matched cohorts, patients undergoing R0 resection had a median overall survival that was 18 months longer than those undergoing R1 resection (34.6 ±â€¯2.0 months vs 16.3 ±â€¯1.7 months, P < .001). Conclusion: In patients presenting with resectable gallbladder adenocarcinoma, margin-negative resection is associated with significant improvement in overall survival.

12.
Integr Med (Encinitas) ; 20(3): 20-29, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34377097

RESUMO

Objective: This study sought to explore constructs of the Whole Health resilience model to identify potential intervention and local research opportunities as a precursor to intervention development, as well as to describe women's resilience in Substance Use Disorder (SUD) recovery including current strengths, coping, self-care, needs and priorities in the context of their everyday lives. Methods: Qualitative data were collected from December 2018 to January 2020 in the Mid-South United States. In-depth interviews of 17 women age 25 to 65 years in SUD recovery for 2 weeks or longer were conducted in 9 different settings including a Medication Assisted Treatment (MAT) hospital setting, a MAT pilot program in a community corrections setting, an incarceration re-entry residential program, community-based peer support organizations (eg, Narcotics Anonymous, Alcoholics Anonymous), a residential SUD treatment facility and a yoga teachers' online group. These data were analyzed with a hybrid approach (inductive and deductive coding). Results: The major themes that emerged from the analysis included social support, individual-level cognitive and spiritual strategies; self-care; stressors, priorities, needs, and self-care barriers and trauma. In this context, women needed a wide range of support including treatment of severe physical injuries, professional psychological support, help with restoring relationships, SUD treatment and recovery services, job training and coaching, health insurance advice, transportation, intimate partner violence (IPV) counseling and housing. Peer-support groups and faith communities were instrumental in many (but not all) of these women's lives in recovery-a gap was identified for women who did not have social support from these groups. Conclusion: These data highlight the need for developing interventions for women in SUD recovery that take a holistic view of resilience life areas, as well as integrate professional services, family support, community support and approach care as wrap-around support that includes integration of social services to meet women's basic needs.

13.
Artigo em Inglês | MEDLINE | ID: mdl-34411699

RESUMO

``Outcomes after cancer resection are traditionally measured individually. Composite metrics, or textbook outcomes, bundle outcomes into a single value to facilitate assessments of quality. We propose a composite outcome for non-small cell lung cancer resections, examine factors associated with the outcome, and evaluate its effect on overall survival. We queried the National Cancer Database for patients with stage I/II non-small cell lung cancer who underwent sublobar resection, lobectomy, or pneumonectomy from 2010 to 2016. We defined the metric as margin-negative resection, sampling of ≥10 lymph nodes, length of stay <75th percentile, no 30-day mortality, no readmission, and receipt of indicated adjuvant therapy. Multivariable logistic regression, Cox proportional hazards modeling, survival analyses, and propensity score matching were used to identify factors associated with the outcome and overall survival. Of 88,208 patients, 70,149 underwent lobectomy, 14,922 underwent sublobar resection, and 3,137 underwent pneumonectomy. Textbook outcome was achieved in 26.3% of patients. Failure to achieve the outcome was most commonly driven by inadequate nodal assessment. Textbook outcome was more likely after minimally invasive surgical approaches (aOR = 1.47; P< 0.001) relative to open resection and less likely after sublobar resection (aOR = 0.20; P< 0.001) relative to lobectomy. Achievement of textbook outcome was associated with an 9.6% increase in 5-year survival (P< 0.001), was independently associated with improved survival (aHR = 0.72; P < 0.001), and remained strongly associated with survival independent of resection extent after propensity matching. One in 4 patients undergoing non-small cell lung cancer resection achieve textbook outcome. Textbook outcome is associated with improved survival and has value as a quality metric.

14.
J Emerg Med ; 2021 Jun 24.
Artigo em Inglês | MEDLINE | ID: mdl-34176685

RESUMO

BACKGROUND: Transgender and gender nonbinary (trans/NB) individuals face many barriers to accessing health care in the United States due to systemic and clinician discrimination. Such experiences can lead to avoidance or delays in seeking care. These issues are relevant for emergency department (ED) clinicians and staff because trans/NB patients may use the ED in times of crisis. OBJECTIVES: The purpose of this study was to qualitatively explore experiences of trans/NB individuals accessing health care in the ED and provide recommendations for improvements. METHODS: This study involved semi-structured qualitative interviews with nine trans/NB individuals living in Arkansas about their experiences when visiting local EDs. RESULTS: Interviews revealed four main themes: 1) system and structural issues; 2) interactions with clinicians/staff influence care received; 3) perceptions of clinician knowledge and education about trans/NB health; and 4) impact on future health and health care access. Participants recommended education for current and future ED clinicians and staff to improve knowledge of best practices for trans/NB health care. Recommendations were also made to improve ED policy for inclusive and affirming intake processes, intake forms, and electronic health record (EHR) documentation, including documentation and use of patients' chosen name and pronouns. CONCLUSION: The negative experiences and discrimination reported by trans/NB patients in ED visits underscores the importance of improving ED clinician knowledge of gender-affirming care practices, ED intake policies and practices, and EHR documentation in EDs.

15.
J Neurosci Res ; 99(8): 1905-1907, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34062005
16.
J Environ Manage ; 295: 113067, 2021 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-34171782

RESUMO

There is a growing need for water managers to refine and optimise environmental flow strategies (e-flows) to balance water requirements for humans and nature. With increasing demands for freshwater and consequent declines in biodiversity, managers are faced with the problem of how to adaptively manage e-flows for multiple stakeholders and species whose flow requirements may overlap or vary. This study assessed the effectiveness of a regulated e-flow release strategy from a dam, aimed at providing movement opportunities and facilitating reproductive processes for multiple threatened species. Movements of 24 Mary River cod (Maccullochella mariensis), 20 Australian lungfish (Neoceratodus forsteri) and 13 Mary River turtle (Elusor macrurus) were quantified using acoustic telemetry over a three-year period. The influence of regulated e-flow releases, season, river depth, water temperature and rainfall on animal movements was assessed using Generalised linear mixed models (GLMMs). Models showed that hydraulic connectivity provided by both natural flows and regulated e-flow releases facilitated movement of all three species between pool habitats, throughout the year. Mary River turtles made extensive use of regulated e-flow releases when moving between habitats, whereas Mary River cod and Australian lungfish required additional natural rises in river height above the regulated e-flows to trigger movements. Significant movement activity was also recorded for cod and turtles during the dry season (winter and spring), broadly coinciding with breeding periods for these species. The effectiveness of, and potential improvements to, current e-flow strategies to sustain key life-history requirements of these species is discussed. Findings suggest a revised e-flow strategy with relatively minor increases in the magnitude of e-flow releases throughout winter and spring, would be effective in providing movement opportunities and supporting reproductive success for all three species. This study demonstrates that by quantifying movement behaviour in an e-flow context, ecological risk assessment frameworks can then be used to assess and provide for critical life-history requirements of multiple species within the context of a highly regulated system under increasing water use demands.


Assuntos
Espécies em Perigo de Extinção , Rios , Animais , Austrália , Ecossistema , Movimentos da Água
17.
J Am Coll Surg ; 233(1): 9-19.e2, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34015455

RESUMO

BACKGROUND: Published studies evaluating the effect of robotic assistance on clinical outcomes and costs of care in diaphragmatic hernia repair (DHR) have been limited. STUDY DESIGN: The Healthcare Cost and Utilization Project State Inpatient and State Ambulatory Surgery and Services Databases for Florida were queried to identify patients undergoing transabdominal DHR between 2011 and 2018 and associated inpatient and outpatient encounters within 12 months after the index operation. Patients undergoing robotic DHR were 1:1:1 propensity score-matched for age, sex, race, Elixhauser comorbidity score, case priority, payer, and facility volume with patients undergoing open and laparoscopic DHR. RESULTS: There were 5,962 patients (67.3%) who underwent laparoscopic DHR, 1,520 (17.2%) who underwent open DHR, and 1,376 (15.5%) who underwent robotic DHR. On comparison of matched cohorts, median index length of stay (3 days; interquartile range [IQR] 2 to 5 days vs 2 days; IQR 1 to 4 days; p < 0.001) and index hospitalization costs ($17,236; IQR $13,231 to $22,183 vs $12,087; IQR $8,881 to $17,439; p < 0.001) for robotic DHR were greater than for laparoscopic DHR. Median length of stay for open DHR (6 days; IQR 4 to 10 days) was longer than that for both laparoscopic and robotic DHR. Median index hospitalization costs for open DHR ($16,470; IQR $11,152 to $23,768) were greater than those for laparoscopic DHR, but less than those for robotic DHR. There were no significant differences between cohorts in the overall rate of post-index care. CONCLUSIONS: Laparoscopic DHR is the most cost-effective approach to DHR. Robotic assistance provides clinical outcomes comparable with laparoscopic DHR, but is associated with increased index cost.


Assuntos
Hérnia Diafragmática/cirurgia , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Análise Custo-Benefício , Bases de Dados Factuais/economia , Bases de Dados Factuais/estatística & dados numéricos , Florida/epidemiologia , Hérnia Diafragmática/epidemiologia , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Laparoscopia/economia , Laparoscopia/estatística & dados numéricos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/economia , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Resultado do Tratamento
19.
Cell Stem Cell ; 28(5): 790-792, 2021 05 06.
Artigo em Inglês | MEDLINE | ID: mdl-33961760

RESUMO

In this issue of Cell Stem Cell, Daniel Bauer and colleagues investigate the pathogenesis of ELANE-associated severe congenital neutropenia (SCN) and describe two potentially universal gene correction strategies for autosomal dominant disorders (Rao et al., 2021). One exploits nonsense-mediated decay to prevent translation of the mutant allele. The other unexpectedly blocks translation by shortening the 3'-UTR.


Assuntos
Elastase de Leucócito , Neutropenia , Edição de Genes , Humanos , Elastase de Leucócito/genética , Mutação , Neutropenia/genética , Virulência
20.
J Am Coll Surg ; 233(1): 120-129.e5, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33887482

RESUMO

BACKGROUND: Mangled extremities are one of the most difficult injuries for trauma surgeons to manage. We compare limb salvage rates for a limb-threatening lower extremity injuries managed at Level I vs Level II trauma centers (TCs). STUDY DESIGN: We identified all adult patients with a limb-threatening injury who underwent primary amputation or limb salvage (LS) using the American College of Surgeons (ACS) Trauma Quality Improvement Program database at ACS Level I vs II TCs between 2007 and 2017. A limb-threatening injury was defined as an open tibial fracture with concurrent arterial injury (Gustilo type IIIc). Multivariable analysis and propensity score matching were performed to minimize confounding by indication. RESULTS: There were 712 records for analysis; 391 (54.9%) LS performed and 321 (45.1%) underwent amputation. The rate of LS was statistically higher among patients treated at Level I TCs vs those treated at Level II TCs (47.4% vs 34.8%; p = 0.01). Patients with penetrating injuries (13% vs 9.5%; p = 0.046) and tibial/peroneal artery injury (72.9% vs 50.4%; p < 0.001), as opposed to popliteal artery injury (30.8% vs 58.8%; p < 0.001), were more likely to have LS. The risk-adjusted odds of LS was 3.13 times higher at Level I TCs vs Level II TCs (95% CI, 1.59 to 6.34; p = 0.001). Limb salvage rates were significantly higher at Level I TCs compared with Level II TCs (53.0% vs 34.8%; p = 0.004), even after propensity matching. CONCLUSIONS: In patients with a mangled extremity, limb salvage rates are 50% higher at Level I TCs compared with Level II TCs, independent of case mix and injury severity.


Assuntos
Fraturas Expostas/cirurgia , Salvamento de Membro/estatística & dados numéricos , Extremidade Inferior/cirurgia , Fraturas da Tíbia/cirurgia , Centros de Traumatologia/estatística & dados numéricos , Lesões do Sistema Vascular/cirurgia , Adulto , Amputação/estatística & dados numéricos , Fraturas Expostas/complicações , Fraturas Expostas/epidemiologia , Humanos , Traumatismos da Perna/complicações , Traumatismos da Perna/epidemiologia , Traumatismos da Perna/cirurgia , Salvamento de Membro/métodos , Extremidade Inferior/lesões , Fraturas da Tíbia/complicações , Fraturas da Tíbia/epidemiologia , Centros de Traumatologia/classificação , Lesões do Sistema Vascular/complicações , Lesões do Sistema Vascular/epidemiologia
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