Arch Surg Chicago
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Multicenter Study
The comparative assessment and improvement of quality of surgical care in the Department of Veterans Affairs.
Prompted by the need to assess comparatively the quality of surgical care in 133 Veterans Affairs (VA) hospitals, the Department of Veterans Affairs conducted the National VA Surgical Risk Study between October 1, 1991, and December 31, 1993, in 44 VA medical centers. The study developed and validated models for risk adjustment of 30-day morbidity and 30-day mortality after major surgery in 8 noncardiac surgical specialties. Similar models were developed for cardiac surgery by the VA's Continuous Improvement in Cardiac Surgery Program. ⋯ The NSQIP also provides an infrastructure to enable the VA investigators to query the database and produce scientific presentations and publications. Since the inception of the NSQIP data collection process, the 30-day postoperative mortality after major surgery in the VA has decreased by 27%, and the 30-day morbidity by 45%. The future of the NSQIP lies in expanding it to the private sector and in enhancing its capabilities by incorporating additional measures of outcome, structure, process, and cost.
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The recommended surgical treatment for chronic neuropathic pain after herniorrhaphy has been a 2-stage operation including: (1) ilioinguinal and iliohypogastric neurectomies through an inguinal approach and (2) genital nerve neurectomy through a flank approach. ⋯ Simultaneous neurectomy of the ilioinguinal, iliohypogastric, and genital nerves without mobilization of the spermatic cord is an effective 1-stage procedure to treat postherniorrhaphy neuralgia. It is performed under local anesthesia and avoids testicular complications. Proximal end implantation of the nerves prevents adherence of the cut ends to the aponeurotic structure of the groin, which can result in recurrence of the pain.
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The female sex steroid 17beta-estradiol improves immune functions following trauma-hemorrhage in rodent models. Therefore, we hypothesized that 17beta-estradiol administration following trauma-hemorrhage would also improve cardiac output, splanchnic perfusion, and oxygen utilization, even after the induction of subsequent sepsis. ⋯ The increase in gut perfusion could represent a potential mechanism for the salutary effects of 17beta-estradiol following trauma-hemorrhage. Because 17beta-estradiol improves systemic and intestinal perfusion after trauma-hemorrhage and induction of subsequent sepsis, this agent appears to be a promising adjunct for the treatment of trauma victims.
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Intravenous patient-controlled analgesia (IV PCA) meperidine hydrochloride can be used with a reasonable margin of safety. ⋯ We recommend 10 mg/kg per day as a maximum safe meperidine hydrochloride dose by an IV PCA device for no longer than 3 days. Daily patient evaluation is mandatory. Care must also be taken when using this dose to ensure the absence of renal dysfunction or enhanced hepatic metabolism of meperidine.