Orientador: Antônio José Maria Cataneo / Resumo: Introdução: O risco de sangramento em cirurgias realizadas na vigência de antitrombóticos preocupa o cirurgião, em contrapartida, a suspensão do agente antitrombótico aumenta o risco de trombose. Esse dilema levou a realização desta revisão. Objetivo: avaliar, por meio de revisão sistemática e metanálise, se há ou não necessidade de suspender medicamentos antitrombóticos orais (varfarina, fluindiona, acenocumarol, AAS e clopidogrel) para a realização de procedimentos eletivos de cirurgia do punho e da mão. Métodos: revisão sistemática de estudos experimentais ou observacionais que tenham avaliado cirurgias de mão e punho na vigência do agente antitrombótico. Foram pesquisadas as bases de dados LILACS, Pubmed, Embase, Cochrane e Scopus, sendo selecionados series com cinco ou mais cirurgias . Os desfechos avaliados foram: complicações graves (necessidade de tratamento cirúrgico) e leves (sem necessidade de tratamento cirúrgico). Resultados : foram selecionados 10 estudos observacionais para análise qualitativa envolvendo 2971 cirurgias. Seis desses estudos foram selecionados para análise quantitativa, envolvendo 319 cirurgias do punho e da mão realizadas na vigência de varfarina, fluindiona, acenocumarol, AAS e clopidogrel e 629 cirurgias realizadas em pacientes sem uso dos antitrombóticos. O risco de complicações leves foi maior nos pacientes que estavam recebendo antitrombóticos ( RR 1,55, IC 95% 1,02 a 2,35; I 2 = 23%, 948 cirurgias), e o risco de complicações graves foi sem... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction : The risks of bleeding in surgeries performed during the antithrombotic period are of concern to the surgeon, and on the other hand, the suspension of the antithrombotic agent increases the risk of thrombosis. This dilemma led to this review. Objective: to evaluate, through a systematic review, whether or not there is a need to suspend antithrombotic drugs (warfarin, fluindione, acenocumarol, ASA and clopidogrel) to perform elective procedures for wrist and hand surgery. Methods: systematic review of experimental or observational studies that have evaluated hand and wrist surgeries during the antithrombotic agent. The databases LILACS, Pubmed, Embase, Cochrane and Scopus were searched, being selected series with five or more surgeries. The outcomes evaluated were: severe complications (need for surgical treatment) and mild complications (no need for surgical treatment). Results: 10 observational studies were selected for qualitative analysis involving 2971 surgeries. Six of these studies were selected for quantitative analysis, involving 319 wrist and hand surgeries performed during warfarin, fluindione, acenocumarol, ASA and clopidogrel and 629 surgeries performed in patients without antithrombotic drugs. The risk of mild complications was greater in patients receiving antithrombotic drugs (RR 1.55, 95% CI 1.02 to 2.35, I 2 = 23%, 948 surgeries), and the risk of severe complications was similar in both groups (RR 1.83, 95% CI 0.32 to 10.29, I 2 = 0%, 948 surger... (Complete abstract click electronic access below) / Mestre

Submitted by FRANCISCO SIMOES DEIENNO (frandeienno@hotmail.com) on 2018-08-14T12:57:37Z No. of bitstreams: 1 Tese Final para Repositorio.pdf: 614767 bytes, checksum: 0f22aeef2c688aa8f97eb3c2d7bc5223 (MD5) / Approved for entry into archive by Sulamita Selma C Colnago null (sulamita@btu.unesp.br) on 2018-08-14T17:14:35Z (GMT) No. of bitstreams: 1 deienno_fs_me_bot.pdf: 614767 bytes, checksum: 0f22aeef2c688aa8f97eb3c2d7bc5223 (MD5) / Made available in DSpace on 2018-08-14T17:14:35Z (GMT). No. of bitstreams: 1 deienno_fs_me_bot.pdf: 614767 bytes, checksum: 0f22aeef2c688aa8f97eb3c2d7bc5223 (MD5) Previous issue date: 2018-07-19 / Introdução: O risco de sangramento em cirurgias realizadas na vigência de antitrombóticos preocupa o cirurgião, em contrapartida, a suspensão do agente antitrombótico aumenta o risco de trombose. Esse dilema levou a realização desta revisão. Objetivo: avaliar, por meio de revisão sistemática e metanálise, se há ou não necessidade de suspender medicamentos antitrombóticos orais (varfarina, fluindiona, acenocumarol, AAS e clopidogrel) para a realização de procedimentos eletivos de cirurgia do punho e da mão. Métodos: revisão sistemática de estudos experimentais ou observacionais que tenham avaliado cirurgias de mão e punho na vigência do agente antitrombótico. Foram pesquisadas as bases de dados LILACS, Pubmed, Embase, Cochrane e Scopus, sendo selecionados series com cinco ou mais cirurgias . Os desfechos avaliados foram: complicações graves (necessidade de tratamento cirúrgico) e leves (sem necessidade de tratamento cirúrgico). Resultados : foram selecionados 10 estudos observacionais para análise qualitativa envolvendo 2971 cirurgias. Seis desses estudos foram selecionados para análise quantitativa, envolvendo 319 cirurgias do punho e da mão realizadas na vigência de varfarina, fluindiona, acenocumarol, AAS e clopidogrel e 629 cirurgias realizadas em pacientes sem uso dos antitrombóticos. O risco de complicações leves foi maior nos pacientes que estavam recebendo antitrombóticos ( RR 1,55, IC 95% 1,02 a 2,35; I 2 = 23%, 948 cirurgias), e o risco de complicações graves foi semelhante nos dois grupos (RR 1,83, IC 95% 0,32 a 10,29; I 2 = 0%, 948 cirurgias). Conclusões: Pacientes em uso de anticoagulantes orais ou antiplaquetários orais tem um risco maior de desenvolver complicações leves, isto é aquelas que não necessitam de reintervenção cirúrgica , quando submetidos a cirurgias do punho e da mão na vigência de tratamento antitrombótico. / Introduction : The risks of bleeding in surgeries performed during the antithrombotic period are of concern to the surgeon, and on the other hand, the suspension of the antithrombotic agent increases the risk of thrombosis. This dilemma led to this review. Objective: to evaluate, through a systematic review, whether or not there is a need to suspend antithrombotic drugs (warfarin, fluindione, acenocumarol, ASA and clopidogrel) to perform elective procedures for wrist and hand surgery. Methods: systematic review of experimental or observational studies that have evaluated hand and wrist surgeries during the antithrombotic agent. The databases LILACS, Pubmed, Embase, Cochrane and Scopus were searched, being selected series with five or more surgeries. The outcomes evaluated were: severe complications (need for surgical treatment) and mild complications (no need for surgical treatment). Results: 10 observational studies were selected for qualitative analysis involving 2971 surgeries. Six of these studies were selected for quantitative analysis, involving 319 wrist and hand surgeries performed during warfarin, fluindione, acenocumarol, ASA and clopidogrel and 629 surgeries performed in patients without antithrombotic drugs. The risk of mild complications was greater in patients receiving antithrombotic drugs (RR 1.55, 95% CI 1.02 to 2.35, I 2 = 23%, 948 surgeries), and the risk of severe complications was similar in both groups (RR 1.83, 95% CI 0.32 to 10.29, I 2 = 0%, 948 surgeries). Conclusions: Patients taking oral anticoagulants or oral antiplatelet agents may be at increased risk of developing mild complications , that is, those that do not require surgical reintervention, when undergoing hand and wrist surgeries during antithrombotic treatment

Made available in DSpace on 2014-12-17T14:03:40Z (GMT). No. of bitstreams: 1 RicheleJAM_DISSERT.pdf: 3022782 bytes, checksum: 46556132e4939175f840346baa8ae21f (MD5) Previous issue date: 2012-10-24 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior / A sepse ? uma doen?a complexa, de alta gravidade e durante o seu desenvolvimento pode ocorrer eventos inflamat?rios graves, que podem levar o paciente ao ?bito. Inibidores de peptidases isolados de sementes de leguminosas est?o sendo estudados devido suas variadas atividades biom?dicas ou farmacol?gicas. Nesse sentido, o presente estudo consistiu na avalia??o das atividades multifuncionais do inibidor de tripsina presente nas sementes de Erythrina velutina (EvTIb). Dois inibidores de tripsina foram purificados por fracionamento com sulfato de am?nio (30-60%), cromatografia de afinidade em tripsina-sepharose e cromatografia de fase reversa. Os inibidores purificados foram denominados de EvTIa e EvTIb e suas massas moleculares determinadas por espectrometria de massa por electrospray (ESI) foram: 19.228,16 Da e 19.210,48 Da, respectivamente. Dentre eles, o EvTIb apresentou maior atividade espec?fica para tripsina e maior percentual de rendimento de extra??o, sendo, portanto, o escolhido para as an?lises adicionais. Os fragmentos desse inibidor gerados por tratamento enzim?tico com tripsina e pepsina foram analisados por espectrometria de massa MALDI-ToF-ToF, permitindo elucidar sua estrutura prim?ria parcial. O EvTIb exibiu uma atividade de inibi??o do tipo n?o-competitiva para a tripsina com IC50 de 22 nmol.L-1 e constante de inibi??o (Ki) de 10 nmol.L-1. Al?m da atividade de inibi??o para tripsina, EvTIb tamb?m inibiu o fator Xa e a elastase neutrof?lica, por?m n?o inibiu trombina, quimotripsina ou peptidase 3. EvTIb se manteve est?vel a varia??o de pH e temperatura. EvTIb n?o foi citot?xico e n?o inibiu o crescimento bacteriano de Escherichia coli e Staphylococcus aureus. EvTIb foi capaz de prolongar o tempo de coagula??o de maneira dose-dependente. Finalmente, observou-se que EvTIb foi capaz de restabelecer os n?veis hemost?ticos, inibir a migra??o leucocit?ria em camundongos s?pticos e diminuir a secre??o de TNF-α e n?o teve a??o sobre a libera??o de IL-6. Por outro lado, EvTIb promoveu um aumento na libera??o de IFN- α e IL-12. Esses dados sugerem que EvTIb pode constituir em uma nova mol?cula com potencial de uso no tratamento da sepse e doen?as relacionadas ? coagula??o

Os progestagênios isolados são contraceptivos indicados que em trombofílicas e/ou com passado de tromboembolismo venoso (TEV). Algumas dessas mulheres, também utilizam anticoagulantes orais (ATCO) o que pode implicar em alterações no padrão de sangramento menstrual associado ao uso de progestagênios isolados. Objetivo: avaliar os efeitos do uso de ATCO no padrão de sangramento associado ao sistema intrauterino liberador de levonorgestrel (SIU-LNG) em mulheres trombofílicas e/ou com passado de TEV . Métodos: Trata-se de um estudo de coorte prospectiva que dividiu as mulheres trombofílicas e/ou com passado de TEV em dois grupos, usuárias de ATCO e não-usuárias de ATCO. Padrão de sangramento, peso, índice de massa corpórea (IMC) e circunferência abdominal foram comparados entre os grupos antes, 6 e 12 meses após a inserção do SIU-LNG. Resultados: Foram incluídas 33 mulheres, entre 18 e 45 anos, 16 usuárias de ATCO e 17 não-usuárias. Houve aumento de 3,9% do peso e 3,8% do IMC em das usuárias de ATCO após 12 meses da inserção do SIU-LNG (p<0,01). Houve aumento de hemoglobina e hematócrito em ambos os grupos. Não se observou diferença entre o padrão de sangramento de ambos os grupos, sendo a amenorréia o padrão mais frequente nos dois grupos (41,2% em ambos) 12 meses após a inserção do SIU-LNG. Utilizar ATCO não aumentou a freqüência e a duranção de sangramento genital. Conclusão: As usuárias e não-usuárias de ATCO tiveram padrão de sangramento semelhante após a inserção do SIU-LNG. Os níveis de hemoglobina e hematócrito aumentaram em ambos os grupos / Background: Progestogen-only contraceptives (POCs) are suitable for women with thrombophilia and/or a history of venous thromboembolism (VTE). Several of these women, however, use oral anticoagulant therapy (OAT), which can impair the bleeding pattern associated with POC use. We evaluated the effects of OAT use on the bleeding pattern associated with the levonorgestrel-releasing intrauterine system (LNG-IUS) in women with thrombophilia and/or a history of VTE. Study Design: This prospective cohort study followed 2 groups of women, all of whom were thrombophilic and/or had a history of VTE: OAT users and non-users. Bleeding patterns, blood pressure, body mass index (BMI), weight, complete blood count and waist circumference were compared between the 2 groups before and 6 and 12 months after LNG-IUS insertion. Results: The patient cohort consisted of 33 women aged 18 to 45 years old, including 16 OAT users and 17 non-users. Body weight increased by 3.9% and BMI by 3.8% in OAT users 12 months after LNG-IUS insertion (p< 0,01). Hemoglobin and hematocrit levels increased by approximately 10% in both groups. There was no difference between the groups in bleeding patterns, with amenorrhea being the most frequent pattern in both groups (41.2% each) 12 months after LNG-IUS insertion. OAT did not increase the frequency of prolonged and/or frequent bleeding. Conclusion: OAT users and non-users had similar bleeding patterns after insertion of the LNG-IUS. Hemoglobin and hematocrit levels increased in both groups

Submitted by Geandra Rodrigues (geandrar@gmail.com) on 2018-10-11T14:26:18Z No. of bitstreams: 1 rafaelguzelladecarvalho.pdf: 5817882 bytes, checksum: 3cecfbefd0364ef85d5c3183dcbdfc47 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2018-10-16T14:07:21Z (GMT) No. of bitstreams: 1 rafaelguzelladecarvalho.pdf: 5817882 bytes, checksum: 3cecfbefd0364ef85d5c3183dcbdfc47 (MD5) / Made available in DSpace on 2018-10-16T14:07:21Z (GMT). No. of bitstreams: 1 rafaelguzelladecarvalho.pdf: 5817882 bytes, checksum: 3cecfbefd0364ef85d5c3183dcbdfc47 (MD5) Previous issue date: 2015-07-23 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Glicosaminoglicanos (GAGs) são heteropolissacarídeos lineares ligados a um núcleo proteico dos proteoglicanos (PGs). Condroitim sulfato (CS) é GAG sulfatado composto por unidades dissacarídicas repetidas de ácido D-glucurônico e N-acetil-galactosamina, esse composto possui atividades biológicas associadas à interação com diferentes elementos da matriz. Estas ações têm sido relacionadas às suas características estruturais relativas ao elevado teor de grupos sulfato e carboxila que originam domínios estruturais que são conhecidos por participar de funções fisiológicas específicas. O presente trabalho teve por objetivo a identificação e caracterização estrutural dos GAGs extraídos de diferentes tecidos de lula (Doryteuthis plei) bem como a avaliação da atividade anticoagulante destes compostos. Para isso inicialmente determinamos a técnica de extração dos GAGs dos tecidos de manto, nadadeira, tentáculos e pele utilizando degradação com enzimas proteolíticas e purificação utilizando a técnica de cromatografia de troca iônica. Realizamos a identificação dos GAGs com degradações com liases específicas (chases AC e B de F. heparinum), em que ficou evidenciado que CS é o GAG majoritário dos tecidos de D. plei. Os CS encontrados tiveram peso molecular detectados na faixa de 30-50 kDa. A dosagem química de sulfato demonstrou que estes CS possuíam relação superior a 1,2 sulfato/hexosamina o que nos forneceu o indicativo que estas macromoléculas eram supersulfatadas. Este fato foi confirmado pela análise por FACE dos produtos da digestão de CS de manto e nadadeira com chase AC de A. aurescens em que a maior sulfatação foi relacionada à presença de alta proporção de resíduos di-sulfatados, ΔDi4,6S (≈55%). Técnicas espectroscópicas de Raman e RMN permitiram confirmar a maior substituição e sulfatação nas posições 4- e 6- da GalNAc, respectivamente. Os CS de manto e nadadeira ainda demonstraram atividade anticoagulante associada à inibição da via intrínseca da coagulação sendo detectada inibição dos fatores IIa e Xa. Desta forma concluímos que CS-E é o tipo de glicosaminoglicano constituinte nos tecidos de lula e que ele possui características tecido-específica, desempenhando sua atividade anticoagulante de acordo com o padrão de sulfatação. / Glycosaminoglycans (GAGs) are linear heteropolysaccharides attached to a core protein of proteoglycans (PGs). Chondroitin sulfate (CS) is sulfated GAG composed of repeating disaccharide units of D-glucuronic acid and N-acetyl-galactosamine, this compound has biological activities associated to their interaction with different components of the extracellular matrix. These activities have been related to their structural characteristics due to the high content of sulfate and carboxyl groups originating structural domains which are known to participate in specific physiological functions. This aim of this study was the identification and structural characterization of glycosaminoglycans extracted from squid different tissues (Doryteuthis plei) as well as evaluation of the anticoagulant activity of these compounds. Initially, we determined the procedures GAGs extraction in mantle tissue, fin, tentacles and skin using degradation with proteolytic enzymes and purification using ion exchange chromatography. We carried out the identification of GAG to degradation with specific lyases (chases AC and B from F. heparinum), wherein we evidenced that CS is the principal GAG of the D. plei tissues. Molecular weight of CS had a range of 30-50 kDa. Quantification of sulfate groups demonstrated that these CS had higher ratio of sulfate/hexosamine (1.2), a indicative that these macromolecules were oversulfated. This fact was confirmed by FACE analysis of CS from mantle and fin after digestion with chase AC from A. aurescens where most sulfation was related to the presence of high proportion of di-sulfated residues, ΔDi4,6S (≈55%). Raman spectroscopic and NMR techniques confirmed the increased substitution and sulfation in positions 4 and 6 of GalNAc, respectively. CS of the mantle and fin demonstrated anticoagulant activity associated with inhibition of the intrinsic coagulation pathway by inhibition of factors Xa and IIa. Thus, we conclude that CS-E is the kind of glycosaminoglycan constituent in squid tissues and it has tissue-specific characteristics, playing their anticoagulant activity according to the sulfation pattern.

Class of 2013 Abstract / Specific Aims:  To determine the efficacy of apixaban when compared to LMWH (enoxaparin) when used as thromboprophylaxis for patients undergoing total hip arthroplasty (THA), total knee arthroplasty (TKA), and medically ill patients  To determine the safety of apixaban when compared to LMWH (enoxaparin) when used as thromboprophylaxis for patients undergoing total hip arthroplasty (THA), total knee arthroplasty (TKA), and medically ill patients Methods: A systematic search of the literature for randomized controlled trials of apixaban thromboprophylaxis therapy versus enoxaparin was conducted using three databases: PubMed, EMBASE, and the Cochrane library. Data from five studies with 12,938 total patients were analyzed using Bayesian random effects meta-analysis. To evaluate efficacy, a composite of venous thromboembolism and death during follow-up was measured. To evaluate safety, major and total bleeding events were considered. Main Results: The odds ratio (OR) for the composite outcome of thromboembolism/death was 0.66 (95% CI: 0.33 to 1.29) for apixaban compared to enoxaparin, while there was a similar risk of major bleeding (OR=1.03, 95%CI: 0.36 to 3.73) and total bleeding (OR=0.92, 95%CI: 0.64 to 1.20). Conclusion: These results suggest a lack of clear superiority of apixaban relative to enoxaparin. Apixaban is an oral alternative with similar efficacy and safety to existing anticoagulant therapies.

Objectifs: Etude de l'influence des cellules du pancréas d'adénocarcinome (BXPC3) et des cellules de carcinome du sein humain (MCF7) sur l'efficacité antithrombotique de l'apixaban, du fondaparinux et de l'énoxaparine. Recherche des mécanismes procoagulants des BXPC3 et MCF7.Méthodes: Les cellules sont cultivées sur plaques 96 puits. Un plasma normal pauvre ou riche en plaquettes est surchargé par des anticoagulants. La génération de thrombine (GT) est réalisée dans différentes conditions par le test CAT. Le facteur tissulaire alternatif épissé (asTF), l'activité du FT (FTa) et le cancer procoagulant (CP) sont évalués. Les cellules HUVEC servent de contrôle normal.Résultats: La comparaison sur la base de l’IC50 a montré qu'en présence de BXPC3 ou de MCF7, l'efficacité de l'apixaban a été préservée. Le fondaparinux est plus vulnérable par la présence de cellules cancéreuses. Le FTa et l’asTF sont plus abondants pour les BXPC3 que les cellules MCF7. La GT est médiée plus fortement par le FVII pour les BXPC3 que les MCF7. Le facteur XII était plus important pour la GT médiée par les MCF7. La présence de MPs augmente considérablement la production de thrombine et cet effet est fonction du type de cellules et leur origine.Conclusion: Le type de cellules cancéreuses est déterminant pour l'efficacité anti-thrombotique des inhibiteurs spécifiques du facteur Xa. La GT par les BXPC3 est dominée par la voie du FT. Le rôle du FXII est plus impliqué pour les MCF7. L'hypercoagulabilité induite par les cellules cancéreuses est la résultante de la combinaison des propriétés procoagulantes des cellules cancéreuses elles-mêmes et des éléments procoagulants du microenvironnement. / Aims: study of influence of pancreas adenocarcinoma cells (BXPC3) and human breast carcinoma cells (MCF7) on the antithrombotic efficiency of apixaban, fondaparinux and enoxaparin. Dissection of procoagulant mechanisms of BXPC3 and MCF7.Methods: Cells were cultured and adhered in 96-well plates. Normal platelet poor or rich plasma were spiked whit apixaban, fondaparinux or enoxaparin. Thrombin generation (TG) was done with CAT¨ assay in different conditions. Alternatively spliced TF (asTF), TF activity (TFa) and cancer procoagulant (CP) were assessed. Primary human umbilical vein cells (HUVEC) were used as normal control.Results: Comparison on the basis of IC50 showed that in the presence of BXPC3 or MCF7 the efficiency of apixaban was preserved. Fondaparinux was more vulnerable to the presence of cancer cells. The TFa and asTF were found in abundant amounts in BXCP3 than MCF7 cells. TG enhancement by BXPC3 and MCF7 was mediated by FVII. Factor XII was more important for TG enhancement by MCF7.The presence of MPs drastically increases the generation of thrombin and this effect depending of the type of their original cells.Conclusion: The type of cancer cells is determinant for the antithrombotic efficiency of the specific factor Xa inhibitors. The mechanism of activation of blood coagulation by the BXPC3 is dominated by the TF pathway, MCF7 additionally imply also FXII activation. The hypercoagulability induced by cancer cells is the resultant of the combination of the procoagulant properties of cancer cells with procoagulant elements of the plasma microenvironment and highlight that circulating MVs are key players in the pathogenesis of cancer-associated thrombosis.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第23057号 / 医博第4684号 / 新制||医||1048(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 森田 智視, 教授 湊谷 謙司, 教授 川上 浩司 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Monogeneans from the family Diplozoidae (subclass Heteronchoinea) are bloodfeeding ectoparasites inhabiting gills of common carp. Digestion of blood in diplozoids is an intracellular process taking place in gut cells within lysosomal cycle in the presence of parasite's peptidases. However, information about the blood digestion comes only from ultrastructural and histochemical analyses. Therefore, I have focused in this work on biochemical and molecular characteristics of bioactive molecules which may participate in blood processing by E. nipponicum adults, especially cysteine peptidases of cathepsin L- and B- types, aspartic peptidases of cathepsin D-type, and Kunitz-type inhibitors of serine peptidases. In homogenates and excretory/secretory (E/S) products of E. nipponicum adults, an activity of cysteine peptidases of cathepsins L-type dominated, followed by an activity of cathepsin D-like aspartic peptidases and a minor cathepsin B-like activity. Inhibitors of the abovementioned peptidase types completely blocked hemoglobinolytic activity in the samples. In the transcriptome of E. nipponicum adults, ten cathepsin L-coding transcripts were found and only one cathepsin B-coding transcript. Primary structures of the encoded enzymes were bioinformatically and phylogenetically compared. Two abundant...

Background: A rural level 1 trauma center underwent a consolidation to level III status in a new trauma network system. A dedicated group of midlevel practitioners emphasizing early mobilization, a geriatric care model, and fall prevention replaced surgical residents in the level 3 center. We hypothesized that outcomes of elderly fall-related injuries may be enhanced with midlevel providers using a geriatric-focused care model. Methods: An IRB-approved trauma registry review of patients over 65 years of age with a fall-related injury admitted to a rural trauma center 1 year prior to and 1 year following a trauma center consolidation from level 1 to level III designation evaluated demographics, anticoagulant use, comorbidities, and clinical outcomes. Statistical analysis included t-test and regression analysis. Results: 327 patients injured by falls were seen over a 2-year study period. The number of patients admitted with a fall-related injury and the injury severity were similar over the study period. Increasing age and anticoagulant use increased length of stay and mortality (both with P <.05). Mortality rates and patient level of independence on discharge were improved in the later period involving midlevel practitioners (both with P <.05). Discussion: Trauma centers and trauma system networks face increasing challenges to provide resources and providers of care for patients injured by falls, especially for the growing elderly population. Midlevel providers focusing on geriatric clinical issues and goals may enhance care and outcomes of elderly fall-related injuries.