American journal of surgery
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Comparative Study
Regional anesthesia as an alternative to general anesthesia for abdominal surgery in patients with severe pulmonary impairment.
It is known that smokers and patients with chronic obstructive pulmonary disease (COPD) experience a higher rate of pulmonary-related complications following abdominal surgery. The impact of anesthetic technique (regional [RA] versus general [GA] versus combination of both) on the complication rate has not been established. This study examined the outcomes of abdominal surgery performed using RA (epidural or continuous spinal) as the sole anesthetic technique in patients with severe pulmonary impairment (SPI). ⋯ Abdominal surgery can be safely performed using RA alone in selected high-risk patients, making this option an attractive alternative to GA for those with severe pulmonary impairment.
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Comparative Study
Improvements in dialysis access survival with increasing use of arteriovenous fistulas in a Veterans Administration medical center.
Native arteriovenous fistulas (AVFs) have been found to exhibit higher survival rates and lower complication rates than prosthetic grafts (AVGs). ⋯ The National Kidney Foundation-Dialysis Outcome Quality Initiative (NKF-DOQI) guidelines for dialysis access reawakened interest in maximizing the use of renal veins for AVF. AVFs created by using the patient's native vein provides the best vascular access for dialysis when compared with prosthetic grafts. AVF has better long-term patency with fewer complications.
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Comparative Study
Evaluating alternative risk-adjustment strategies for surgery.
Comparison of institutional health care outcomes requires risk adjustment. Risk-adjustment methodology may influence the results of such comparisons. ⋯ In surgical patients, different risk-adjustment methodologies afford divergent estimates of mortality risk.
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Editorial Comparative Study
Why should the VA continue academic affiliations?
Academic affiliations between VA medical centers and medical schools have made an important contribution to the healthcare of veterans and the education of physicians over the last 60 years. The rationale for these affiliations and their establishment following World War II is discussed. The circumstances leading to affiliations and the benefit they afford veterans remain pertinent today.
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To examine early and late toxicities, evaluate cosmetic results, and determine the need for reoperation or additional diagnostic procedures in patients treated with accelerated partial breast irradiation (APBI) delivered by way of an interstitial implant in breast-conserving therapy. ⋯ In selected patients with early-stage breast cancer, APBI with targeted interstitial brachytherapy offers 5-year results comparable with conventional breast-conserving therapy employing whole-breast radiation therapy. Minimal long-term toxicities were noted, most of which demonstrated continued resolution over time. Acceptable acute (7%) and delayed (4%) infection rates were observed. Fat necrosis was identified with increasing frequency with time, but the majority was asymptomatic. Cosmetic results are good to excellent (>90%). Continued follow-up by the surgeon will be required to determine the long-term efficacy of this alternative treatment approach.