The American surgeon
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The American surgeon · Feb 2004
Multicenter StudyNonsentinel lymph node status after positive sentinel lymph node biopsy in early breast cancer.
Axillary dissection is the current standard of care for patients with breast cancer who are diagnosed with metastasis to axillary sentinel lymph nodes (SLNs). Recently, that concept has come under increasing scrutiny because not all women with a positive SLN will need further dissection. The purpose of this study was to look at nonsentinel lymph node status in patients with breast cancer and axillary SLN metastasis in an effort to determine tumor variables that can guide further treatment if there are additional axillary nodes involved. ⋯ The presence of palpable breast mass (P = 0.03), tumor size (P = 0.04), angiolymphatic invasion (P = 0.03), and extracapsular extension of SLN metastasis (P = 0.001) were the variables that predicted non-SLN involvement. Micrometastasis was inversely related to non-SLN involvement. In patients with breast cancer and SLN metastasis, the presence of a palpable breast mass, tumor size, angiolymphatic invasion, and extracapsular node extension increase the likelihood of identifying additional node metastasis on subsequent axillary dissection.
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The American surgeon · Feb 2004
Predictors of mortality in patients with traumatic diaphragmatic rupture and associated thoracic and/or abdominal injuries.
This is a retrospective review of 731 patients sustaining diaphragmatic trauma over a 22 year period (1980-2002) at an urban level I trauma center. Patients had an average injury severity score (ISS) of 22 +/- 12. The mortality rate (MR) was 23 per cent (168/731). ⋯ Multivariate analysis revealed blunt trauma, blood transfusions, ISS, and pancreatic injury as the most significant independent predictors of infection (P < 0.001). The initial physiologic presentation of the patient and the severity of hemorrhagic shock are the primary determinants for survival. Prompt identification of associated injuries with rapid control of bleeding is paramount to survival.
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The American surgeon · Feb 2004
Residents' working hours in a consortium-wide surgical education program.
Traditional work schedules of surgical residents have been cited as a factor that negatively influences education and the quality of patient care. Demands by federal and state legislators as well as the general public have forced a re-evaluation of the issue. Long working hours and resulting sleep deprivation affect the lives of residents profoundly, but the question remains does it lower the quality of medical care? The justification for the long hours is that they are vital to medical education, but residents are so drained by their schedules that they are rarely in the best state of mind to learn from their experiences. ⋯ The results of our study indicates that the majority of residents in general surgery programs in Michigan perceive a need for reform of work schedules. Surgical educators may have underestimated this need in the past. Most residents thought that long hours impaired their educational experience and at times compromised their clinical care.
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Despite surgical advances, antimicrobial therapy, and intensive care, the morbidity and mortality of intra-abdominal sepsis remains high. The primary purpose of this study was to determine whether open abdomen management of intra-abdominal sepsis reduces intensive care unit (ICU) and hospital mortality. The records of 81 consecutive patients with open abdomen management for intra-abdominal sepsis admitted to the surgical ICU from January 1998 to April 2002 were retrospectively reviewed. ⋯ An overall fistula rate of 14.8 per cent was demonstrated in the open abdomen patients. A significant difference in overall ICU and hospital mortality was not demonstrated between patients treated with open abdomen management and historical controls. A prospective randomized study accounting for extent of sepsis may define a role for open abdomen management in selected subgroups of patients.