In the last decade, we have seen a steady increase in the incidence of frontal sinus trauma due to gunshot wounds and a decrease in motor vehicle trauma. Penetrating gunshot wounds to the frontal ...sinus present a unique challenge to the reconstructive surgeon because they require careful consideration of the management principles of plastic surgery. Despite previous reviews on frontal sinus trauma, there are no studies examining the management techniques of frontal sinus fractures due specifically to gunshot wounds. In this study, we aim to retrospectively evaluate the use of a variety of tissue flaps in intervention and associated outcomes.
A retrospective chart review was completed on all patients with gunshot wound(s) to the frontal sinus from January 2010 to January 2018 at a single institution. The patients were classified based on the fracture pattern (anterior vs posterior table vs both), degree of displacement, presence of nasofrontal outflow tract injury, and evidence of cerebrospinal fluid leak. Patients were then stratified according to the type of reconstruction performed (cranialization, obliteration and need for free flap) and evaluated for major and minor complications after reconstruction.
In this study, we present outcome data from 28 cases of frontal sinus trauma due to gunshot wounds. There was a statistically significant difference (P = 0.049) in the type reconstructive strategy employed with each type of flap, with pericranial flaps primarily used in cranialization, temporal grafts were more likely to be used in obliteration, and free flaps were more likely to be used in cranialization. The overall major complication rate was 52% (P = 0.248), with the most common acute major complication was cerebrospinal fluid leak (39%) and major chronic was abscess (23.5%).
This report explores the management of frontal sinus trauma and presents short-term outcomes of treatment for penetrating gunshot wounds at a tertiary referral center.
OBJECTIVES/GOALS: Health insurance status is associated with differences in access to healthcare and health outcomes. The objective of this study was to test the hypothesis that among infants born in ...the United States, maternal private insurance compared with public Medicaid insurance would be associated with a lower infant mortality rate (IMR). METHODS/STUDY POPULATION: This ecological study used data from the Center for Disease Control and Prevention (CDC) WONDER expanded linked birth and infant death records database 2017-2018. We included hospital-born infants from 20 to 42 weeks of gestational age (wga) if the mother had either private or Medicaid insurance. We excluded infants with congenital anomalies and infants who died due to congenital anomalies. We used negative-binomial regression adjusted for race, sex, multiple birth, and any maternal pregnancy risk factors (as defined by the CDC) to determine the difference in IMR between private and Medicaid insurance. Chi-square or Fishers exact test was used to compare differences in categorical variables between groups. RESULTS/ANTICIPATED RESULTS: We included 6,901,328 infants; 53.6% had private insurance and 46.4% were insured by Medicaid. Privately insured infants had a lower IMR compared with Medicaid insured infants (2.84/1000 vs. 5.32/1000; adjusted relative risk (aRR) 0.71; 95% confidence intervals (CI) 0.62 to 0.81; p<.0001). The privately insured had higher rates of 1st trimester prenatal care compared to those with Medicaid (85.6% vs. 66.6%; p<.00001). Rates of infant morbidity and maternal morbidity (per CDC definitions) were lower among the privately insured compared to those with Medicaid (both p<.00001). The privately insured had lower rates of preterm (9.1% vs. 11.0%), extremely preterm (0.5% vs. 0.7%), low birth weight (7.1% vs. 9.6%), and extremely low birth weight (0.5% vs. 0.7%) births compared to those with Medicaid (all p<0.001). DISCUSSION/SIGNIFICANCE: Private insurance is associated with a lower IMR compared to Medicaid insurance. Privately insured pregnancies also have higher rates of early prenatal care, less morbidity, and less preterm and low birth weight births. There may be opportunities to improve access to care and pregnancy outcomes among Medicaid insured pregnancies in the United States.
Rates of maternal morbidity and mortality experienced by women in the United States have been shown to vary significantly by race, most commonly attributed to differences in access to healthcare and ...socioeconomic status. Recent data showed that Asian Pacific Islanders have the highest rate of maternal morbidity despite having a higher socioeconomic status. In the military, women of all races are granted equal access to healthcare, irrespective of socioeconomic class. We hypothesized that within the military, there would be no racial disparities in maternal outcomes because of universal healthcare.
This study aimed to evaluate if universal access to healthcare, as seen in the military healthcare system, leads to similar rates of maternal morbidity regardless of racial or ethnic background.
This was a retrospective cohort study of data from the National Perinatal Information Center reports obtained from participating military treatment facilities from April 2019 to March 2020 and included 34,025 deliveries. We compared racial differences in the incidence of each of the following 3 outcomes: postpartum hemorrhage, severe maternal morbidity among women with postpartum hemorrhage including transfusion, and severe maternal morbidity among women with postpartum hemorrhage excluding transfusion.
A total of 41 military treatment facilities (a list of participating military treatment facilities are provided in the Appendix) provided data that were included. There was an increased rate of postpartum hemorrhage (relative risk, 1.73; 95% confidence interval, 1.45–2.07), severe maternal morbidity including transfusion (relative risk, 1.22; 95% confidence interval, 0.93–1.61), and severe maternal morbidity excluding transfusion (relative risk, 1.97; 95% confidence interval, 1.02–3.8) among Asian Pacific Islander women when compared with Black or White women.
Even with equal access to healthcare in the military, Asian Pacific Islander women experience statistically significant increased rates of postpartum hemorrhage and severe maternal morbidity excluding transfusion when compared with Black or White women. The increased rates of severe maternal morbidity including transfusion were not statistically significant.
Background
Skeletal muscle dysfunction is a common extrapulmonary manifestation of chronic obstructive pulmonary disease (COPD). Alterations in skeletal muscle myosin heavy chain expression, with ...reduced type I and increased type II myosin heavy chain expression, are associated with COPD severity when studied in largely male cohorts. The objectives of this study were (1) to define an abnormal myofibre proportion phenotype in both males and females with COPD and (2) to identify transcripts and transcriptional networks associated with abnormal myofibre proportion in COPD.
Methods
Forty‐six participants with COPD were assessed for body composition, strength, endurance and pulmonary function. Skeletal muscle biopsies from the vastus lateralis were assayed for fibre‐type distribution and cross‐sectional area via immunofluorescence microscopy and RNA‐sequenced to generate transcriptome‐wide gene expression data. Sex‐stratified k‐means clustering of type I and IIx/IIax fibre proportions was used to define abnormal myofibre proportion in participants with COPD and contrasted with previously defined criteria. Single transcripts and weighted co‐expression network analysis modules were tested for correlation with the abnormal myofibre proportion phenotype.
Results
Abnormal myofibre proportion was defined in males with COPD (n = 29) as <18% type I and/or >22% type IIx/IIax fibres and in females with COPD (n = 17) as <36% type I and/or >12% type IIx/IIax fibres. Half of the participants with COPD were classified as having an abnormal myofibre proportion. Participants with COPD and an abnormal myofibre proportion had lower median handgrip strength (26.1 vs. 34.0 kg, P = 0.022), 6‐min walk distance (300 vs. 353 m, P = 0.039) and forced expiratory volume in 1 s‐to‐forced vital capacity ratio (0.42 vs. 0.48, P = 0.041) compared with participants with COPD and normal myofibre proportions. Twenty‐nine transcripts were associated with abnormal myofibre proportions in participants with COPD, with the upregulated NEB, TPM1 and TPM2 genes having the largest fold differences. Co‐expression network analysis revealed that two transcript modules were significantly positively associated with the presence of abnormal myofibre proportions. One of these co‐expression modules contained genes classically associated with muscle atrophy, as well as transcripts associated with both type I and type II myofibres, and was enriched for genetic loci associated with bone mineral density.
Conclusions
Our findings indicate that there are significant transcriptional alterations associated with abnormal myofibre proportions in participants with COPD. Transcripts canonically associated with both type I and type IIa fibres were enriched in a co‐expression network associated with abnormal myofibre proportion, suggesting altered transcriptional regulation across multiple fibre types.
INTRODUCTION: The American Society of Colposcopy and Cervical Pathology (ASCCP) guidelines were updated in January 2023 to broaden the use of endocervical curettage (ECC) at the time of colposcopy. ...We aimed to determine how our practice at a single military institution aligned with the new recommendations. METHODS: After receiving approval from our institutional quality improvement (QI) office, a retrospective chart review was completed for all colposcopies performed at Brooke Army Medical Center from March 1, 2022 to December 31, 2022. Demographic and dysplasia history was extracted for each encounter. Cases were sorted into ASCCP-defined categories of ECC preferred, recommended, acceptable, omission acceptable, and unacceptable. The rate of endocervical curettage completion was compared across each category. RESULTS: Colposcopies were performed in 120 nonpregnant patients. ECC was performed in 95 cases (79%). Based on 2023 guidelines, ECC would be recommended for 57, preferred for 23, acceptable for 25, and omission acceptable for 15. The rates of ECC for recommended (84%) and preferred groups (82.5%) and omission acceptable group (73%) were not significantly different ( P =NS). CONCLUSION: Prior to release of the 2023 ASCCP guidelines, ECC at our institution was commonly done in higher-risk groups. To mitigate overall health care burden and unindicated procedures, ECCs should be redistributed away from the omission acceptable groups towards the higher-risk groups. This would lead to an estimated 2.5% increase in overall ECC rate and a 20% increase in high-risk groups. A prospective evaluation of the implication of these guidelines is ongoing.
INTRODUCTION:
Maternal morbidity and mortality rates in the United States have increased in the last two decades with a disproportionate effect on women of color. Military Tricare coverage models ...universal health care access; however, in studies looking at births in military treatment facilities, disparities still exist for women of color. This study analyzes maternal delivery outcomes for all women with Tricare coverage including deliveries in the civilian sector.
METHODS:
Data from 6.2 million births in the Centers for Disease Control and Prevention WONDER Linked Birth/Infant Death Records for 2017–2019 were analyzed for all-cause morbidity (transfusions, perineal lacerations, uterine rupture, unplanned hysterectomy, and intensive care unit admissions), severe maternal morbidity (SMM) (excludes lacerations), and SMM excluding transfusion. Risk ratios were calculated comparing overall maternal morbidity rates between Tricare, Medicaid, self-pay, and private insurance. In addition, risk ratios were calculated between insurance types stratified by race.
RESULTS:
Compared to private insurance, Tricare insurance had significantly reduced risk of all-cause maternal morbidity. Compared to White women, Black women with Tricare and all other insurances had a decreased risk of all-cause morbidity, but a significantly increased risk of SMM and SMM without transfusion. Asian women had significant increased risk of all-cause, SMM and SMM without transfusion. There was no significant difference in the risk of morbidity for women of color with Tricare insurance compared to women of color with Medicaid, private, or self-pay insurance.
CONCLUSION:
The risk of severe maternal morbidity remains elevated for women of color despite access to Tricare health insurance.
INTRODUCTION:
Rates of maternal morbidity and mortality experienced by women in the United States have been shown to vary significantly by race, most commonly attributed to differences in access to ...health care and socioeconomic status. Recent data shows that Asian Pacific Islander (API) have highest rate of maternal morbidity, despite having higher socioeconomic status. In the military, women of all races are granted equal access to health care, irrespective of socioeconomic class. We hypothesized that within the military there would be no racial disparities in maternal outcome due to universal health care.
METHODS:
A retrospective cohort study included data from National Perinatal Information Center report from participating military treatment facilities from April 2019 to March 2020, totaling 36,861 deliveries. We compared racial differences in percentages in each of the following three categories: postpartum hemorrhage (PPH) and severe maternal morbidity (SMM) among women with postpartum hemorrhage including and excluding transfusion.
RESULTS:
MTFs included in the data showed an increased rate of PPH (RR, 1.73; 95% CI, 1.45–2.07), SMM including transfusion (RR, 1.22; 95% CI, 0.93–1.61), and SMM excluding transfusion (RR, 1.97; 95% CI, 1.02–3.8) in API women when compared to women of Black and White race.
CONCLUSION:
Even with equal access to health care in the military, API women experience increased rates of adverse maternal outcomes when compared to Black or White women. This highlights the need to continue to include API as a separate race for data collection and calls for further research into possible causes of this health care disparity.
INTRODUCTION:
In the United States, Black women die at 2.5 times the rate of White women and 3.5 times the rate of Hispanic women. These racial health care disparities have been largely attributed to ...access to health care and other social determinants of health. We hypothesize that the military health care system models universal health care access seen in other developed countries and should equalize these rates.
METHODS:
Delivery data from 41 military treatment facilities across the Department of Defense (Army, Air Force, and Navy), including over 36,000 deliveries from 2019 to 2020, were compiled in a convenience dataset through the National Perinatal Information Center. After aggregation, the parameters of percent of deliveries complicated by severe maternal morbidity (SMM) and percent of SMM secondary to preeclampsia with and without transfusion were calculated. Risk ratios were calculated by race for the resulting summary data. American Indian/Alaska Native patients were excluded due to a limited total number of deliveries, preventing statistical analyses.
RESULTS:
Overall, the risk of SMM was increased among Black women compared to White women. The risk of SMM related to preeclampsia showed no significant difference among races with or without transfusion. When other races were set as reference group, there was a significant difference for White women, suggesting a protective effect.
CONCLUSION:
While women of color still experience overall SMM at higher rates than their White counterparts, Tricare may have equalized the risk of SMM for deliveries complicated by preeclampsia.
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