Annals of surgery
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Emergency cesarean sections in trauma patients are not justified and should be abandoned. ⋯ In pregnant trauma patients, infant viability is defined by the presence of FHTs, estimated gestational age greater than or equal to 26 weeks. In viable infants, survival after emergency cesarean section is acceptable (75%). Infant survival is independent of maternal distress or Injury Severity Score. Sixty percent of infant deaths resulted from delay in recognition of fetal distress and cesarean section. These were potentially preventable. Given the definition of fetal viability, our initial hypothesis is invalid.
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Comparative Study
A statewide, population-based time-series analysis of the outcome of ruptured abdominal aortic aneurysm.
The purpose of this study was to perform the first statewide, population-based, time-series analysis of the frequency of ruptured abdominal aortic aneurysm (RAAA), to determine the outcomes of RAAA, and to assess the association of patient, physician, and hospital factors with survival after RAAA. The hypotheses of the study were as follows: 1) the rate of RAAA would increase over time and 2) patient, surgeon, and hospital factors would be associated with survival. ⋯ Ruptured abdominal aortic aneurysm remains a highly lethal lesion, even in the best of hands. Despite the many improvements in the care of seriously ill patients, there was no significant improvement in the survival of RAAA during this study. This suggests that early diagnosis is the best hope of survival in these patients. The study demonstrated that survival after RAAA was related most strongly to patient age at the time of the RAAA. The physician's and the hospital's experience with RAAA, the physician's background as measured by board certification, and the type of hospital at which the operation was performed (small vs. large) also may be associated with survival. These findings may have important implications for the regionalization of care and the education and credentialling of physicians. Given the lack of recent progress of improving the outcome of RAAA, aggressive efforts to treat patients before rupture are appropriate.
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Heart and lung transplantation has gained acceptance as therapy for end-stage cardiac and pulmonary failure. The early and intermediate survival benefits of one center's 10-year experience with 177 patients undergoing thoracic transplantation were examined. ⋯ Cardiac and pulmonary transplantation can be applied to morbidly ill patients with excellent operative and intermediate-term survival.
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The incidence, associated injury pattern, diagnostic factors, risk for adverse outcome, and efficacy of anticoagulant therapy in the setting of blunt and carotid injury (BCI) were evaluated. ⋯ Blunt carotid injury is more common than appreciated, seen in 0.67% of patients admitted after motor vehicle accidents. Therapy with heparin is highly efficacious, significantly reducing neurologic morbidity and mortality. Heparin therapy, when instituted before onset of symptoms, ameliorates neurologic deterioration. Liberal screening, leading to earlier diagnosis, would improve outcome.
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Permanent hypoparathyroidism is a recognized complication of thyroidectomy. Operative strategies to prevent this complication include preservation of parathyroid glands in situ and autotransplantation of parathyroid glands resected or devascularized during thyroidectomy. ⋯ Although preservation of parathyroid glands in situ is desirable, routine parathyroid autotransplantation during thyroidectomy virtually eliminates postoperative hypoparathyroidism. Normal parathyroid glands resected or devascularized during thyroidectomy for well-differentiated thyroid carcinoma or benign disease should be transplanted in the sternocleidomastoid muscle. Patients with Multiple Endocrine Neoplasia type 2A should have parathyroid glands resected at the time of thyroidectomy for medullary thyroid carcinoma and transplanted in the nondominant forearm. Postoperative management in most patients after thyroidectomy and parathyroid autotransplantation involves temporary calcium and vitamin D replacement and close biochemical evaluation. This precautionary measure of parathyroid autotransplantation markedly reduces the incidence of permanent postoperative hypoparathyroidism.