JAMA surgery
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Comparative Study
Combined Epidural-General Anesthesia vs General Anesthesia Alone for Elective Abdominal Aortic Aneurysm Repair.
Epidural analgesia (EA) is used as an adjunct procedure for postoperative pain control during elective abdominal aortic aneurysm (AAA) surgery. In addition to analgesia, modulatory effects of EA on spinal sympathetic outflow result in improved organ perfusion with reduced complications. Reductions in postoperative complications lead to shorter convalescence and possibly improved 30-day survival. However, the effect of EA on long-term survival when used as an adjunct to general anesthesia (GA) during elective AAA surgery is unknown. ⋯ Combined EA-GA was associated with improved survival and significantly lower HRs and ORs for mortality and morbidity in patients undergoing elective AAA repair. The survival benefit may be attributable to reduced immediate postoperative adverse events. Based on these findings, EA-GA should be strongly considered in suitable patients.
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The quality of surgical care in the Veterans Health Administration improved markedly in the 1990s after implementation of the Veterans Affairs (VA) National Surgical Quality Improvement Program (now called the VA Surgical Quality Improvement Program). Although there have been many recent evaluations of surgical care in the private sector, to date, a contemporary global evaluation has not been performed within the VA health system. ⋯ For the past 15 years, morbidity, mortality, and FTR have improved within the VA health system. Other integrated health systems providing a high volume of surgical care for their enrollees may benefit by critically evaluating the system-level approaches of the VA health system to surgical quality improvement.
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Failure of bone fracture healing occurs in 5% to 10% of all patients. Nonunion risk is associated with the severity of injury and with the surgical treatment technique, yet progression to nonunion is not fully explained by these risk factors. ⋯ The probability of fracture nonunion can be based on patient-specific risk factors at presentation. Risk of nonunion is a function of fracture severity, fracture location, disease comorbidity, and medication use.
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Multicenter Study Comparative Study
Bariatric Surgery and Long-term Durability of Weight Loss.
Bariatric surgery induces significant weight loss for severely obese patients, but there is limited evidence of the durability of weight loss compared with nonsurgical matches and across bariatric procedures. ⋯ Patients in the Veterans Administration health care system lost substantially more weight than nonsurgical matches and sustained most of this weight loss in the long term. Roux-en-Y gastric bypass induced significantly greater weight loss among veterans than SG or AGB at 4 years. These results provide further evidence of the beneficial association between surgery and long-term weight loss that has been demonstrated in shorter-term studies of younger, predominantly female populations.
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Trauma patients are at high risk for developing venous thromboembolism (VTE). The VTE rate when enoxaparin sodium is dosed by anti-factor Xa (anti-Xa) trough level is not well described. ⋯ In this study, subprophylactic anti-Xa trough levels were common in trauma patients. Enoxaparin dosage adjustment may lead to a reduced rate of VTE without an increased risk of bleeding.