In the past nine years, 1196 patients whose lower extremity was threatened because of infrainguinal arteriosclerosis have been treated at Montefiore Hospital. In the last six years, limb salvage was attempted in 679 or 90% of 755 patients. Femoropopliteal (318), small vessel (204) and axillopopliteal (29) bypasses were used along with transluminal angioplasty (128) and aggressive local operations to obtain a healed foot. Immediate (one month) limb salvage was achieved in 583 or 86% of the 679 patients in whom revascularization was possible. The 30-day mortality rate was 3%. The cumulative life table (LT) survival rate of all the patients undergoing reconstructive arterial operations was 48% at five years. The cumulative LT limb salvage rate after all reconstructive arterial operations was 66% at five years. The cumulative LT patency rate of femoropopliteal bypasses was not influenced by angiographic outflow characteristics of the popliteal artery but was increased 15% by appropriate reoperations to 67% at five years. Cumulative LT patency and limb salvage rates of small vessel and axillopopliteal bypasses were more than 50% at two years. Of patients undergoing arterial reconstruction, 88% of those who died within five years did so without losing their limbs. Of all the patients in whom limb salvage was attempted, 68% lived more than one year with a viable, useable extremity, and 54% lived over two years with an intact limb. We believe this aggressive approach to limb salvage is justified, and can be undertaken with a low cost in mortality, knee loss and morbidity.
The primary protocol presented for the treatment of ear keloids produces durable results, with an acceptably low recurrence rate. Stratification of keloids based on an assessment of aggressiveness may allow for a more informed choice in their optimal treatment.
Objective
This study estimates the impact of a statewide centralized emergency department telepsychiatry service provided in non-psychiatric emergency departments on use of mental health services.
Methods
Individuals treated via telepsychiatry were compared to a matched sample of individuals with mental health diagnoses who were treated in non-participating hospitals. Bivariate and two part and generalized linear regression models were used to assess differences in outpatient follow up, admission following the emergency department visit, length of stay, inpatient and total costs between the two groups.
Results
Between March 2009 and June 2013 there were 9,066 patients with at least one telepsychiatry visit. Of these, 7,261 had index telepsychiatry visits which we were able to successfully match. The telepsychiatry group was more likely to receive 30 day outpatient follow up than the matched controls (46% versus 16%, p,.001) and more likely to receive 90 day outpatient follow up (54% versus 20%, p<.001). Those receiving telepsychiatry were less likely to be admitted to the hospital at the index emergency department visit than the control group (11% versus 22%). The combined effect of having a telepsychiatry consult during the index emergency department visit was a 0.86 day reduction in inpatient length of stay associated with receiving telepsychiatry care. 30-day inpatient costs were $2,336 (p=0.04) lower for the telepsychiatry group. 30-day total health care costs were not statistically different.
Conclusions
Telepsychiatry delivered in the emergency department through a centralized coordinated program has great promise for improving linkage with outpatient mental health services while reducing inpatient utilization and hospital costs.
Any of the reviewed techniques are safe in practice; however, there is a learning curve associated with their use, and longer follow-up will allow for the identification of late complications. The double incision with nipple transposition on a pedicle technique can be considered for patients for whom depigmentation of the nipple-areola complex is a significant concern, especially if they are willing to tolerate a potentially suboptimal chest contour.
Summary:
A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.
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