American journal of surgery
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Comparative Study
A comparison of carotid artery stenting with neuroprotection versus carotid endarterectomy under local anesthesia.
Carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce the risk of stroke in patients with high-grade carotid artery stenosis. Despite the known impact of type of anesthesia on outcome after CEA, none of the current studies comparing CEA with CAS addresses the effect of anesthetic choice on perioperative events. In this study, we compare our results of distally protected CAS versus CEA under local anesthesia. ⋯ Percutaneous carotid stenting with neuroprotection provides comparable clinical success to CEA performed under local anesthetic. Further studies are warranted to validate the long-term efficacy of CAS and to elucidate patient selection criteria for endovascular carotid revascularization.
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Veterans Administration (VA) medical centers have had a long history of providing medical care to those who have served their country. Over time, the VA has evolved into a facility that has had a major role in graduate medical education. In surgery, this had provided experience in the medical and surgical management of complex surgical disease involving the head and neck, chest, and gastrointestinal tract, and in the fields of surgical oncology, peripheral vascular disease, and the subspecialties of urology, orthopedics, and neurosurgery. ⋯ This is not the case for the Department of Veterans Affairs. With the congressionally mandated charge for the VA to compare its quality to private clinicians, the advent of the "Surgery Package" became possible. The VA will continue its leadership position in the healthcare arena if it can successfully address the challenges facing it.
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Multicenter Study Comparative Study
Surgical resident supervision in the operating room and outcomes of care in Veterans Affairs hospitals.
There has been concern that a reduced level of surgical resident supervision in the operating room (OR) is correlated with worse patient outcomes. Until September 2004, Veterans' Affairs (VA) hospitals entered in the surgical record level 3 supervision on every surgical case when the attending physician was available but not physically present in the OR or the OR suite. In this study, we assessed the impact of level 3 on risk-adjusted morbidity and mortality in the VA system. ⋯ Between 1998 and 2004, the level of resident supervision in the OR did not affect clinical outcomes adversely for surgical patients in the VA teaching hospitals.
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In the operating room (OR), poor communication among the surgeons, anesthesiologists, and nurses may lead to adverse events that can compromise patient safety. A survey performed at our institution showed low communication ratings from surgeons, anesthesiologists, and OR nursing staff. Our objective was to determine if communication in the operating room could be improved through medical team training (MTT). ⋯ Medical team training using crew resource management principles can improve communication in the OR, ensuring a safer environment that leads to decreased adverse events.
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Comparative Study
Postoperative day one: a high risk period for respiratory events.
In 2001, the Joint Commission on Accreditation of Healthcare Organizations released Pain Management Standards that has led to an increased focus on pain control. Since then the Institute for Safe Medication Practices has noted that overaggressive pain management has led to increases in oversedation and fatal respiratory depression. One of our previous studies found that postoperative patients may be reaching dangerously high levels of sedation as a result of pain management. Our hypothesis is that postoperative patients who have a respiratory event caused by analgesic use are more likely to have that event in the first postoperative day. ⋯ The first 24 hours after surgery represents a high-risk period for a respiratory event as a result of narcotic use. The realization of this risk can lead to the implementation of standards to increase patient safety in the first postoperative day.