Journal of the American College of Surgeons
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Clinical Trial Controlled Clinical Trial
A randomized, prospective trial of standard Hickman compared with Groshong central venous catheters in pediatric oncology patients.
Safe and reliable central venous access is critical in the management of children with cancer. A recently described valved catheter (Groshong) requires less frequent flushing to preserve catheter patency, theoretically reducing daily care costs for the catheter as well as lessening the risk of mechanical or infectious complications. This study compared standard Hickman to Groshong catheters in a group of pediatric oncology patients. ⋯ When considering the cost of complications, Groshong catheters were no less expensive to maintain compared with standard Hickman catheters. Furthermore, Groshong catheters malfunctioned more frequently and required a greater number of urokinase instillations for withdrawal occlusion. The use of the Groshong catheter in pediatric oncology patients cannot be supported by the present study.
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Randomized Controlled Trial Clinical Trial
A prospective randomized study of end points of resuscitation after major trauma: global oxygen transport indices versus organ-specific gastric mucosal pH.
Gastric tonometry, as a method of organ-specific monitoring of the status of the splanchnic circulation, has demonstrated prognostic and therapeutic implications in critically ill patients. The experience with this method in patients with trauma has been limited. ⋯ Gastric mucosal pH may be an important marker to assess the adequacy of resuscitation. Monitoring of pHi may provide early warning for systemic complications in the postresuscitation period.
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Selective nonoperative management of adults with blunt splenic injury continues to evolve. Predictive factors associated with successful nonoperative management have primarily been clinical criteria such as hemodynamic stability and the degree of associated injuries. This study evaluates the role of patient selection in the safety and success of nonoperative management of adults with blunt splenic injury. ⋯ Nonoperative management of adults with blunt splenic injury commonly fails in older patients independent of other clinical and radiographic variables. We conclude that age over 55 years is a contraindication to nonoperative management of patients with blunt splenic injury.
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Randomized Controlled Trial Comparative Study Clinical Trial
The Pittsburgh randomized trial of tacrolimus compared to cyclosporine for hepatic transplantation.
Tacrolimus (formerly FK506) was first used clinically in 1989 to successfully replace cyclosporine in hepatic transplant recipients who were experiencing intractable rejection or as the baseline drug from the time of operation. After extensive pilot experience, an institutional review board-mandated clinical trial comparing cyclosporine with tacrolimus was performed. ⋯ Seventy-nine patients were randomized to the tacrolimus arm and 75 to the cyclosporine arm during 1990 and 1991. All patients were available for follow-up throughout the trial, which terminated on May 30, 1995. The mean duration of follow-up was four years. Patients randomized to the tacrolimus arm were less likely to experience acute rejection than were those receiving cyclosporine, with 36.2 percent of the patients receiving tacrolimus and 16.8 percent of the patients receiving cyclosporine showing freedom from rejection at one year (p = 0.003, likelihood ratio test). Survival of patients over the course of the study was virtually the same in the two groups.
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Elderly patients are often viewed as high-risk surgical candidates. Recent reports, however, have recommended applying the standard surgical approach to this group. Many of these series report mortality rates that are substantially higher than those in the younger population. Therefore, the applicability of these procedures for the elderly may be questionable. ⋯ The results support the view that elective colorectal resection in the elderly population is worthwhile and should be performed for the same indications as in younger patients. Although emergent operations were associated with a poor outcome, the majority of the patients survived and left the hospital.