American journal of surgery
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Despite spectacular advances in life-support technology, the management of patients with severe sepsis continues to be a significant health care challenge because of the associated major morbidity, high mortality, and health economic implications. Severe sepsis with associated multisystem organ dysfunction (MOD) is the leading cause of death in the intensive care unit. Recent understanding of the pathophysiology now demonstrates that the syndrome of severe sepsis after a major physiologic insult is characterized by the activation of multiple overlapping and interacting cascades leading to systemic inflammation, a procoagulant state, and decreased fibrinolysis, which if unchecked leads to the progressive functional deterioration of multiple interdependent organs. This review will highlight the epidemiology, current understanding of the pathophysiology, management, and prevention of the syndrome of severe sepsis with MOD.
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After resuscitation from hemorrhagic shock, intestinal microvessels constrict leading to impairment of blood flow. This occurs despite restoration and maintenance of central hemodynamics. Our recent studies have demonstrated that topical and continuous exposure of the gut microvasculature to a clinical solution (Delflex; Fresenius Medical Care), as a technique of direct peritoneal resuscitation (DPR), reverses the postresuscitation vasoconstriction and hypoperfusion to a sustained dilation and hyperperfusion. We hypothesize that initiation of DPR simultaneously with resuscitation from hemorrhagic shock enhance organ blood flow to all tissues surrounding the peritoneal cavity as well as distant organs. ⋯ Direct peritoneal resuscitation enhanced blood flow to organs incited in the pathogenesis of multiple organ failure that follows hemorrhagic shock.
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This study was performed to determine the impact of an endovascular program (EVP) on open and endovascular abdominal aortic aneurysm (AAA) operations in a residency training institution. ⋯ An endovascular program has a positive impact on the aortic aneurysm practice in an academic institution, as evidenced by the significant increase in annual endovascular AAA cases despite a decrease in open AAA operations. Although vascular fellows continued to maintain sufficient experience in both open and endovascular AAA operations, general surgery chief residents suffered a significant decrease in their open AAA experience. Further evaluation of the residency system is warranted to better optimize the training paradigm of both vascular fellowship and general surgery residency.
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This article reviews employers' attempts over the past 25 years to address the cost and accessibility of health care services for their employees and the effect these efforts have had on U. S. health care delivery. The difficulties in aligning the interests of all parties in a third-party health beneficiary contract are examined. ⋯ Such plans differ from fee-for-service and managed care models in terms of the economic alignment of the parties. Consumer-driven plans align the employer's economic interest with the employee/patient, and reduce health benefit costs by providing information, tools, and direct economic incentives to employees for self-management of health care dollars. Because these incentives are designed to reduce the consumption of services, providers are the party left out of economic alignment under the consumer-driven model.