Journal of the American College of Surgeons
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Randomized Controlled Trial Multicenter Study
Onset of Coagulation Function Recovery Is Delayed in Severely Injured Trauma Patients with Venous Thromboembolism.
Altered coagulation function after trauma can contribute to development of venous thromboembolism (VTE). Severe trauma impairs coagulation function, but the trajectory for recovery is not known. We hypothesized that enhanced, early recovery of coagulation function increases VTE risk in severely injured trauma patients. ⋯ Recovery from platelet dysfunction and coagulopathy after severe trauma were delayed in VTE patients. Suppressed clot lysis and compensatory mechanisms associated with altered coagulation that can potentiate VTE formation require additional investigation.
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Multicenter Study
Rural General Surgery: A 38-year Experience with a Regional Network Established by an Integrated Health System in the Midwestern United States.
General surgeon (GS) workforce shortages are predicted to worsen, particularly in rural areas. We report on a sustainable model for delivery of GS services within a large rural region that includes an integrated health system. ⋯ Successful recruitment of rural GSs depends on competitive salary, reasonable call and leave schedules, administrative support, and adequate case variety and volume. Case volume is enhanced by cooperative relationships with CAHs, health system assistance in performing appropriate procedures locally, co-management of complex cases, and development of outreach surgical locations. In addition to the recruitment principles mentioned, rural GS retention is optimized by connectivity with the main campus medical center.
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Multicenter Study
Sex-Specific Differences in Colon Cancer When Quality Measures Are Adhered To: Results from International, Prospective, Multicenter Clinical Trials.
There is no consensus on the relationship between patient sex and the location, stage, and oncologic outcome of colon cancer (CC). We hypothesized that there is a sex-specific difference in the biology and management of CC. ⋯ This is the first prospective study to demonstrate sex-specific differences in location and T stage of CC when surgical and pathologic management adhered to strict quality standards. The predominance of right-sided CC in females suggests that flexible sigmoidoscopy may be inadequate for screening and surveillance. Interestingly, earlier stage and right-sided location did not confer a DFS or OS advantage for women. Additional studies are needed to determine why females have a higher propensity for right-sided lesions and a potential difference in CC biology.
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Post-discharge surgical care fragmentation is defined as readmission to any hospital other than the hospital at which surgery was performed. The objective of this study was to assess the impact of fragmented readmissions within the first year after orthotopic liver transplantation (OLT). ⋯ Post-discharge fragmentation significantly increases the risk of both 30-day mortality and subsequent readmission after a readmission in the first year after OLT. More inpatient visits before a readmission and less time elapsed from index surgery increase the odds of an adverse event after discharge from a fragmented readmission. These parameters could guide transfer decisions for patients with post-discharge fragmentation.
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Patients diagnosed with a malignancy must decide whether to travel for care at an academic center or receive treatment at a nearby hospital. Here we examine differences in demographics, treatment, and outcomes of those traveling to academic centers for their care vs those not traveling, as well as compare travel for an aggressive vs indolent malignancy. ⋯ There are improvements in both quality and survival for those traveling to academic centers for their cancer care. In the case of PTC, this difference in quality did not affect overall survival. In PDAC, however, differences in quality translated to a survival advantage.