Journal of the American College of Surgeons
-
Racial disparities in renal transplantation outcomes have been documented with inferior allograft survival among African Americans compared with non-African Americans. These differences have been attributed to a variety of factors, including immunologic hyperresponsiveness, socioeconomic status, compliance, HLA matching, and access to care. The purpose of this study was to examine both immunologic and nonimmunologic risk factors for allograft loss with a goal of defining targeted strategies to improve outcomes among African Americans. ⋯ Advances in immunosuppression regimens have contributed to allograft survival in both early and late (constant) phases throughout all eras, but improvement in longterm outcomes for African Americans continues to lag behind non-African Americans. The disparity in renal allograft loss between African Americans and non-African Americans over time indicates that beyond immunologic risk, the impact of nonimmunologic variables, such as time on dialysis pretransplantation, diabetes, and access to medical care, can be key issues.
-
Significant confusion exists about management of blunt carotid injuries (BCI). Currently, three common treatments are being used without significant longterm followup data to demonstrate efficacy. Although heparin has been shown to reduce in-hospital stroke rates, antiplatelet therapy (aspirin and clopidogrel) has emerged as an alternate therapy without proved efficacy; carotid stenting has also been implemented for pseudoaneurysms (13% BCI), but its utility has recently been challenged. This is the first study to assess longterm efficacy of various therapeutic approaches. ⋯ Longterm followup of BCI demonstrates that antithrombotic therapy prevents cerebral infarction; antiplatelet therapy and anticoagulation are equally effective; and carotid stents appear to be safe and effective for lesions that develop pseudoaneurysms or extensive dissections.
-
All physicians must be vigilant in the pursuit of safe care for patients. While problems in care are identified, education that provides an understanding of these problems and guidelines for improvement can enhance patient safety. Our objective was to determine problematic aspects of surgical care, including care provided by surgeons before, during, after, and instead of surgery, that negatively affect patient safety. ⋯ Closed claims reviews provide valuable data that may enhance provider performance through heightened awareness of common unsafe practices. Specifically, opportunities exist to improve surgical care provided during the preoperative and postoperative phases of treatment through continuing medical education to improve patient safety.
-
Randomized Controlled Trial Multicenter Study
Postoperative ileus-related morbidity profile in patients treated with alvimopan after bowel resection.
Postoperative ileus (POI), an interruption of coordinated bowel motility after operation, is exacerbated by opioids used to manage pain. Alvimopan, a peripherally acting mu-opioid receptor antagonist, accelerated gastrointestinal (GI) recovery after bowel resection in randomized, double-blind, placebo-controlled, multicenter phase III POI trials. The effect of alvimopan on POI-related morbidity for patients who underwent bowel resection was evaluated in a post-hoc analysis. ⋯ Alvimopan 12 mg was associated with reduced POI-related morbidity compared with placebo, without compromising opioid-based analgesia in patients undergoing bowel resection. Relatively low NNTs are clinically meaningful and reinforce the potential benefits of alvimopan for the patient and health care system.
-
Induction of a profound hypothermia for emergency preservation and resuscitation in severe hemorrhagic shock can improve survival from lethal injuries, but the impact of hypothermia on bleeding and infectious complications has not been completely determined. ⋯ Induction of profound hypothermia can preserve the viability of key organs during repair of lethal injuries. This strategy can be used even in the presence of solid organ and bowel injuries to improve survival, without any considerable increase in postoperative complication rates.