We have previously demonstrated that Emergency General Surgery (EGS) patients treated at high-volume hospitals experience lower mortality rates than those treated at low-volume hospitals. However, ...EGS comprises a wide spectrum of diseases. Our goal was to determine which EGS diseases had better outcomes at high-volume hospitals.
We undertook a retrospective analysis of the National Inpatient Sample database for 2013 (a nationwide representative sample). Patients with EGS diseases were identified using American Association for the Surgery of Trauma definitions. A hierarchical logistic regression model was used to measure risk-adjusted probability of death, adjusting for age, sex, race, ethnicity, insurance type, and comorbidities. Patients were then grouped into 16 risk groups based upon their predicted probability of death. We then compared observed mortality rates at high- versus low-volume hospitals within each risk group.
Nationwide, 3,006,615 patients with EGS diseases were treated at 4,083 hospitals in 2013. Patients with predicted risk of death of 4% or higher (275,615 patients, 9.2%) had lower observed mortality rates at high-volume hospitals than at low-volume hospitals (7.7% vs. 10.2%, p < 0.001). We estimated that 1,002 deaths were potentially preventable if high-risk patients who were treated at low-volume hospitals were instead transferred to high-volume hospitals.
EGS patients with predicted risk of death of 4% or higher experience lower mortality rates at high-volume hospitals than at low-volume hospitals. A regional system of EGS care that enables rapid transfer of high-risk patients to high-volume hospitals may prevent several deaths.
Prognostic and epidemiological, level III; Therapeutic/Case Management, level IV.
Soil protists are increasingly appreciated as essential components of soil foodwebs; however, there is a dearth of information on the factors structuring their communities. Here we investigate the ...importance of different biotic and abiotic factors as key drivers of spatial and seasonal distribution of protistan communities. We conducted an intensive survey of a 10 m
grassland plot in Germany, focusing on a major group of protists, the Cercozoa. From 177 soil samples, collected from April to November, we obtained 694 Operational Taxonomy Units representing >6 million Illumina reads. All major cercozoan taxonomic and functional groups were present, dominated by the small flagellates of the Glissomonadida. We found evidence of environmental selection structuring the cercozoan communities both spatially and seasonally. Spatial analyses indicated that communities were correlated within a range of 3.5 m. Seasonal variations in the abundance of bacterivores and bacteria, followed by that of omnivores suggested a dynamic prey-predator succession. The most influential edaphic properties were moisture and clay content, which differentially affected each functional group. Our study is based on an intense sampling of protists at a small scale, thus providing a detailed description of the biodiversity of different taxa/functional groups and the ecological processes involved in shaping their distribution.
A genetic etiology is identified for one-third of patients with congenital heart disease (CHD), with 8% of cases attributable to coding de novo variants (DNVs). To assess the contribution of ...noncoding DNVs to CHD, we compared genome sequences from 749 CHD probands and their parents with those from 1,611 unaffected trios. Neural network prediction of noncoding DNV transcriptional impact identified a burden of DNVs in individuals with CHD (n = 2,238 DNVs) compared to controls (n = 4,177; P = 8.7 × 10
). Independent analyses of enhancers showed an excess of DNVs in associated genes (27 genes versus 3.7 expected, P = 1 × 10
). We observed significant overlap between these transcription-based approaches (odds ratio (OR) = 2.5, 95% confidence interval (CI) 1.1-5.0, P = 5.4 × 10
). CHD DNVs altered transcription levels in 5 of 31 enhancers assayed. Finally, we observed a DNV burden in RNA-binding-protein regulatory sites (OR = 1.13, 95% CI 1.1-1.2, P = 8.8 × 10
). Our findings demonstrate an enrichment of potentially disruptive regulatory noncoding DNVs in a fraction of CHD at least as high as that observed for damaging coding DNVs.
Spatial and temporal processes shaping microbial communities are inseparably linked but rarely studied together. By Illumina 16S rRNA sequencing, we monitored soil bacteria in 360 stations on a 100 ...square meter plot distributed across six intra-annual samplings in a rarely managed, temperate grassland. Using a multi-tiered approach, we tested the extent to which stochastic or deterministic processes influenced the composition of local communities. A combination of phylogenetic turnover analysis and null modeling demonstrated that either homogenization by unlimited stochastic dispersal or scenarios, in which neither stochastic processes nor deterministic forces dominated, explained local assembly processes. Thus, the majority of all sampled communities (82%) was rather homogeneous with no significant changes in abundance-weighted composition. However, we detected strong and uniform taxonomic shifts within just nine samples in early summer. Thus, community snapshots sampled from single points in time or space do not necessarily reflect a representative community state. The potential for change despite the overall homogeneity was further demonstrated when the focus shifted to the rare biosphere. Rare OTU turnover, rather than nestedness, characterized abundance-independent β-diversity. Accordingly, boosted generalized additive models encompassing spatial, temporal and environmental variables revealed strong and highly diverse effects of space on OTU abundance, even within the same genus. This pure spatial effect increased with decreasing OTU abundance and frequency, whereas soil moisture – the most important environmental variable – had an opposite effect by impacting abundant OTUs more than the rare ones. These results indicate that – despite considerable oscillation in space and time – the abundant and resident OTUs provide a community backbone that supports much higher β-diversity of a dynamic rare biosphere. Our findings reveal complex interactions among space, time, and environmental filters within bacterial communities in a long-established temperate grassland.
We report herein that synergistic light absorption in the optical near-field enables nanoscale self-organization during inorganic phototropic growth. Se–Te was grown electrochemically under ...illumination from an incoherent, unstructured light source in geometrically constrained, wavelength scale areas. Despite the limited dimensions, with as few as two discrete features produced in a single sub-micron dimension, the deposit morphology exhibited defined order and anisotropy. Computer modeling analysis of light absorption in simulated structures revealed a synergy wherein light capture in a nanoscale feature was enhanced by the presence of additional adjacent features, with the synergistic effect originating predominantly from nearest neighbor contributions. Modeling moreover indicated that synergistic absorption is produced by scattering of the incident illumination by individual nanoscale features, leading to a local increase in the near-field intensity and consequently increasing the absorption in neighboring features. The interplay between these optical processes establishes the basis for spontaneous order generation via inorganic phototropic growth.
Multiple ligament knee injuries (MLKIs) represent a spectrum of injury patterns that are often associated with concomitant musculoskeletal and neurovascular injuries, complex treatment, and ...postoperative complications. However, there has not been high-level evidence describing the presentation and treatment of MLKIs. The purpose of this multicenter retrospective study was to describe characteristics of MLKIs, their management, and related complications using a pathoanatomic MLKI classification system based on the Schenck Knee Dislocation classification system.
This review identified and analyzed MLKIs that occurred between 2011 and 2015. Cases with an MLKI were included in this study if there was a complete tear of ≥2 ligaments and at least 1 ligament was repaired or reconstructed. Cases in which a ligament was deemed clinically incompetent due to a partial ligament tear and required surgical repair or reconstruction were considered equivalent to grade-III tears for inclusion and classification. Demographic information, the mechanism of injury, times from injury to presentation to an orthopaedic surgeon and to surgery, the ligament injury pattern, associated injuries, surgical procedures, and complications were captured. Data were analyzed descriptively.
A total of 773 individuals from 14 centers who underwent surgery for an MLKI were reviewed. The mean age of the individuals was 30.5 ± 12.7 years, and 74.2% were male. The most common mechanism involved sports (43.2%). The median time from injury to presentation to the orthopaedic surgeon was 11 days (interquartile range IQR, 3 to 48 days), and the time to initial ligament surgery was 64 days (IQR, 23 to 190 days). While the most common injury patterns were an anterior cruciate ligament tear combined with either a medial-sided (MLK 1-AM, 20.7%) or lateral-sided (MLK 1-AL, 23.2%) injury, one-third (34.7%) were bicruciate injuries. Associated injuries most often involved menisci (55.6%), nerves (18.5%) and tendons (15.6%). The method of surgical intervention (repair versus reconstruction), external fixator use, and staging of procedures varied by MLKI classification. Loss of motion (11.4%) was the most common postoperative complication.
A better understanding of the clinical characteristics and management of the various MLKI patterns can be used to support clinical decision-making and individualized treatment of these complex injuries, and may ultimately lead to enhanced outcomes and reduced associated risks.
Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.
Acidobacteria occur in a large variety of ecosystems worldwide and are particularly abundant and highly diverse in soils. In spite of their diversity, only few species have been characterized to date ...which makes
one of the most poorly understood phyla among the domain Bacteria. We used a culture-independent niche modeling approach to elucidate ecological adaptations and their evolution for 4,154 operational taxonomic units (OTUs) of
across 150 different, comprehensively characterized grassland soils in Germany. Using the relative abundances of their 16S rRNA gene transcripts, the responses of active OTUs along gradients of 41 environmental variables were modeled using hierarchical logistic regression (HOF), which allowed to determine values for optimum activity for each variable (niche optima). By linking 16S rRNA transcripts to the phylogeny of full 16S rRNA gene sequences, we could trace the evolution of the different ecological adaptations during the diversification of
. This approach revealed a pronounced ecological diversification even among acidobacterial sister clades. Although the evolution of habitat adaptation was mainly cladogenic, it was disrupted by recurrent events of convergent evolution that resulted in frequent habitat switching within individual clades. Our findings indicate that the high diversity of soil acidobacterial communities is largely sustained by differential habitat adaptation even at the level of closely related species. A comparison of niche optima of individual OTUs with the phenotypic properties of their cultivated representatives showed that our niche modeling approach (1) correctly predicts those physiological properties that have been determined for cultivated species of
but (2) also provides ample information on ecological adaptations that cannot be inferred from standard taxonomic descriptions of bacterial isolates. These novel information on specific adaptations of not-yet-cultivated
can therefore guide future cultivation trials and likely will increase their cultivation success.
Thousands of colonoscopies were canceled during the initial surge of the COVID‐19 pandemic. As facilities resumed services, some patients were hesitant to reschedule. The purpose of this study was to ...determine whether a decision aid plus telephone coaching would increase colorectal cancer (CRC) screening and improve patient reports of shared decision making (SDM). A randomized controlled trial assigned adults aged 45–75 without prior history of CRC who had a colonoscopy canceled from March to May 2020 to intervention (n = 400) or usual care control (n = 400) arms. The intervention arm received three‐page decision aid and call from decision coach from September 2020 through November 2020. Screening rates were collected at 6 months. A subset (n = 250) in each arm was surveyed 8 weeks after randomization to assess SDM (scores range 0–4, higher scores indicating more SDM), decisional conflict, and screening preference. The sample was on average, 60 years old, 53% female, 74% White, non‐Hispanic, and 11% Spanish speaking. More intervention arm patients were screened within 6 months (35% intervention vs 23% control, p < 0.001). The intervention respondents reported higher SDM scores (mean difference 0.7 0.4, 0.9, p < 0.001) and less decisional conflict than controls (−21% −35%, −7%, p = 0.003). The majority in both arms preferred screening versus delaying (68% intervention vs. 65% control, p = 0.75). An SDM approach that offered alternatives and incorporated patients' preferences resulted in higher screening rates. Patients who are overdue for CRC screening may benefit from proactive outreach with SDM support.
Many patients who had their colonoscopies cancelled or postponed due to the COVID‐19 pandemic were hesitant to reschedule. This randomized trial found that a brief shared decision making intervention significantly increased colorectal cancer screening uptake and improved the quality of screening decisions over usual care.
Developing controllable doping processes for two-dimensional (2D) semiconductors is critical to developing next-generation electronic and optoelectronic devices. Understanding the nature of the ...contacts is an essential step in realizing efficient charge injection in transition metal dichalcogenides. In this study, post-growth n-doping of chemical vapor deposition grown monolayer (1 L) WS2 is achieved through molecular reductant solution treatment. The doping level can be effectively controlled by the treatment time and dopant solution concentrations. The doped WS2 field-effect transistors showed profound threshold voltage shifts and tunable channel currents. This molecular n-doping technique is beneficial for the selective area doping needed for electrical contacts and reduces the contact resistance (Rc) in 1 L WS2 by more than two orders of magnitude. The significant reduction of Rc is attributed to the high electron-doping density achieved in WS2, which leads to a significant reduction of the Schottky barrier height. The dependence of mobility on temperature indicates clear evidence of the strong suppression of charge-impurity scattering after doping. High levels of doping allow the observation of a metal–insulator transition in monolayer WS2 due to strong electron–electron interactions. This doping technique provides a viable route for tailoring the electrical properties and improving the contacts in transition metal dichalcogenides, paving the way for high-performance 2D nanoelectronic devices.
Abstract Background context Existing literature on adult spinal deformity (ASD) offers little guidance regarding an evidence-based approach to care. To optimize the value of medical treatment, a ...thorough understanding of the cost of surgical treatment for ASD is required. Purpose To evaluate four clinically and radiographically distinct groups of ASD and identify and compare the cost of surgical treatment among the groups. Study design/setting Multicenter retrospective study of consecutive surgeries for ASD. Patient sample Three hundred twenty-five consecutive ASD patients treated between 2008 and 2010. Outcome measures Cost data were collected from hospital administrative records on the direct costs (DCs) incurred for the episode of surgical care, excluding overhead. Methods Based on preoperative radiographs and history, patients were categorized into one of four diagnostic categories of deformity: primary idiopathic scoliosis (PIS), primary degenerative scoliosis (PDS), primary sagittal plane deformity (PSPD), and revision (R). Analysis of variance and generalized linear model regressions were used to analyze the DCs of surgery and to assess differences in costs across the four diagnostic categories considered. Results Significant differences were observed in DC of surgery for different categories of ASD, with surgical treatment for PDS the most expensive followed in decreasing order by PSPD, PIS, and R (p<.01). Results further revealed a significant positive relationship between age and DC (p<.01) and a significant positive relationship between length of stay and DC (p<.01). Among PIS patients, for every incremental increase in levels fused, the expected DC increased by $3,997 (p=.00). Fusion to pelvis also significantly increased the DC of surgery for patients aged 18 to 29 years (p<.01) and 30 to 59 years (p<.01) but not for 60 years or more (p=.86). Conclusions There is an increasing DC of surgery with increasing age, length of hospital stay, length of fusion, and fusions to the pelvis. Revision surgery is the least expensive surgery on average and should therefore not preclude its consideration from a pure cost perspective.
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