American journal of surgery
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Nosocomial pneumonia is frequent and is associated with high mortality in intubated mechanically ventilated patients. To determine whether there is a significant relationship between subclinical aspiration from nasogastric feeding and development of nosocomial pneumonia, we studied 24 ventilated patients who received nasogastric feeding. Endotracheal aspirates were tested twice daily for the presence of glucose using a glucose oxidase reagent strip. ⋯ The remaining five patients had nonbloody glucose-positive endotracheal aspirates and all developed nosocomial pneumonia. There was a significantly greater incidence of pneumonia among patients who had nonbloody glucose-positive aspirates than among patients without glucose-positive aspirates (p less than 0.001, Fisher's exact test). We conclude that subclinical aspiration of nasogastric feeding, as detected by nonbloody glucose-positive endotracheal aspiration, is associated with the development of nosocomial pneumonia.
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Mitral valve repair for mitral regurgitation has been reported to have more favorable early and late results than mitral valve replacement. From July 1985 through July 1990, 63 patients have undergone valve repair at Good Samaritan Hospital. Twenty-two men and 41 women whose ages ranged from 34 to 81 years (mean 67.9 years) were treated. ⋯ There have been two valve-related late failures requiring reoperation. Based on this early experience, we conclude that valve repair compared with mitral valve replacement has a low operative mortality with good early results. Continued efforts to preserve native mitral valve function in the presence of mitral regurgitation appear justified.
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We reviewed the management and clinical course of 21 patients with extrahepatic injuries to the portal triad seen over the past 11 years at a Level I trauma center. These represented only 0.21% of patients with multiple trauma admitted during this time. Portal triad injury was never specifically diagnosed preoperatively. ⋯ Complications necessitating reoperation or percutaneous drainage procedures were encountered in 8 of 10 surviving patients (80%). Injuries to the portal triad are uncommon, difficult to diagnose, and technically challenging. Mortality is most directly related to uncontrolled intraabdominal hemorrhage, and salvage requires rapid control of bleeding as the first treatment priority.
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Despite the lack of scientific data comparing it with traditional open operations, laparoscopic surgery has gained rapid acceptance and implementation by general surgeons. Individual hospitals, which have the responsibility for developing their own privileging criteria, are searching for guidance as to the amount and type of additional training required to grant clinical privileges in laparoscopic general surgery. ⋯ Therefore, until such techniques are regularly included in general surgery residency programs, additional training for and granting of separate privileges in laparoscopic surgery are appropriate. Adequate training for surgeons already experienced in abdominal and biliary tract surgery can be acquired through a preceptorship in diagnostic laparoscopy, attending a course in laparoscopic surgery that includes both didactic instruction and live animal experience, assisting with the procedures in humans, and being proctored and certified as competent by an experienced general surgeon.
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Basic scientists and clinicians have written numerous articles on the diverse causes of adult respiratory distress syndrome (ARDS). There is no specific diagnostic test for ARDS; the condition is characterized by interstitial lung edema, reduction in lung compliance, alveolar and small airway closure, decrease in functional residual capacity, and persistent hypoxia with increasing amounts of pulmonary blood flow coursing through nonventilated or poorly ventilated alveoli. Recent studies have emphasized the roles of macrophages and polymorphonuclear neutrophils in lung defense and injury. ⋯ ARDS is not a single disease process, but appears to represent a final common pathway for the manifestation of a variety of lung injuries. The goal of therapy is to eliminate the predisposing condition and support the patient. New modes of ventilatory and pharmacologic therapy are presented.