JAMA surgery
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Reduction in length of hospital stay is a veritable target in reducing the overall costs of health care. However, many existing approaches are flawed because the assumptions of what cause excessive length of stay are incorrect; we methodically identified the right targets in this study. ⋯ System-related issues, not severity of illness, prolong hospital stay excessively. Cost-reduction efforts should target operational bottlenecks between acute and postacute care.
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Surgical site infections (SSIs) are the focus of numerous quality improvement initiatives because they are a common and costly cause of potentially preventable patient morbidity. Superficial and deep/organ-space SSIs differ in terms of anatomical location and clinical severity. ⋯ Risk factors for superficial SSI and deep/organ-space SSI vary in terms of magnitude and significance, suggesting that these SSI types are somewhat different disease processes. Groups interested in preventing SSIs might improve success by considering these SSI types independently for root-cause analyses and development of best practices and interventions.
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Although projections of surgical workforce predict an increased need for general surgeons, especially in rural areas, graduates of residency programs increasingly enter urban or metropolitan specialty practice. ⋯ Providing residents a dedicated and significant experience in a rural setting increases the likelihood that they will practice general surgery in a similar setting despite initial specialty plans. Implementing such programs might help alleviate the increasing gap in workforce needs of small towns and rural hospitals.
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The evolution of damage control strategies has led to significant changes in the use of resuscitation after traumatic injury. ⋯ There has been a shift toward a reduced crystalloid volume and the recreation of whole blood from component products in resuscitation. These changes are associated with markedly improved outcomes and a new paradigm in the resuscitation of severely injured patients.
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Comparative Study
Prospective evaluation of the role of computed tomography in the assessment of abdominal stab wounds.
An important adjunct in the management of abdominal gunshot wounds, the role of computed tomography (CT) in the diagnostic workup of abdominal stab wounds remains controversial. ⋯ In this prospective evaluation of abdominal stab wound management, serial physical examination was able to discriminate between patients requiring a therapeutic laparotomy and those who could be safely observed. A physical examination-based diagnostic algorithm was effective and decreased radiation burden in the management of abdominal stab wounds.