Journal of the American College of Surgeons
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The aim of this study was to report on the early experiences using a real-time 3-dimensional (3D) virtual reality navigation system with open MRI for breast-conserving surgery. ⋯ Real-time 3D virtual reality navigation system with open MRI is feasible for safe and accurate excision of nonpalpable MRI-detected breast tumors. Long-term outcomes of this technique should be evaluated further.
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Early clinical trials investigating the role of tightly controlled glucose levels showed marked benefit in survival of critically ill patients. However, a recent meta-analysis and large randomized controlled trial have failed to reproduce the benefit, showing instead substantially increased risk of dangerous hypoglycemia. We sought to investigate the effects of varying glucose concentrations on previously tested, prognostically significant, innate immune parameters, to define any potential effects of glucose at the cellular level. ⋯ Increasing glucose concentrations exert considerable opposing effects on several well-established innate immunologic processes. The opposing findings might contribute to recent clinical controversies. Physician judgment and experience are essential to imminent treatment of critically ill and perioperative surgical patients.
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Recent years have seen the establishment of bariatric surgery credentialing processes, center-of-excellence programs, and fellowship training positions. The effects of center-of-excellence status and of the presence of training programs have not previously been examined. The objective of this study was to examine the effects of case volume, center-of-excellence status, and training programs on early outcomes of bariatric surgery. ⋯ The hypothesized positive volume-outcomes relationship of bariatric surgery is shown without arbitrarily categorizing hospitals to case volume groups, by analysis of volume as a continuous variable. Institutions with a dedicated fellowship training program have also been shown, in part, to be associated with improved outcomes. The concept of volume-dependent center-of-excellence programs is supported, although no independent association with the credentialing process is noted.
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Preoperative risk assessment is important yet inexact in older patients because physiologic reserves are difficult to measure. Frailty is thought to estimate physiologic reserves, although its use has not been evaluated in surgical patients. We designed a study to determine if frailty predicts surgical complications and enhances current perioperative risk models. ⋯ Frailty independently predicts postoperative complications, length of stay, and discharge to a skilled or assisted-living facility in older surgical patients and enhances conventional risk models. Assessing frailty using a standardized definition can help patients and physicians make more informed decisions.
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For trauma patients requiring massive blood transfusion, aggressive plasma usage has been demonstrated to confer a survival advantage. The aim of this study was to evaluate the impact of plasma administration in nonmassively transfused patients. ⋯ For nonmassively transfused trauma patients, plasma administration was associated with a substantial increase in complications, in particular ARDS, with no improvement in survival. An increase in multiple organ dysfunction, pneumonia, and sepsis was likewise seen as increasing volumes of plasma were transfused. The optimal trigger for initiation of a protocol for aggressive plasma infusion warrants prospective evaluation.