Surgery
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Multicenter Study
A case-cohort study of postoperative myocardial infarction: impact of anemia and cardioprotective medications.
Postoperative myocardial infarction (poMI) is a serious and costly complication. Multiple risk factors for poMI are known, but the effect of anemia and cardioprotective medications have not been defined in real-world surgical practice. ⋯ In the current era, poMI patients have a markedly increased risk of death. This risk is decreased with preoperative use of acetylsalicylic acid and post MI β-blockade. Further study is warranted to explore the role of anemia and cardiac interventions after poMI.
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Clinical Trial
Borderline and locally advanced pancreatic adenocarcinoma margin accentuation with intraoperative irreversible electroporation.
Complete tumor extirpation (R0 resection) remains the best possibility for long-term survival in patients with pancreatic adenocarcinoma. Unfortunately, approximately 80% of patients are not amenable to resection at diagnosis either because of metastatic (40%) or locally advanced disease (40%). Recent reports of irreversible electroporation (IRE), a high-voltage, short-pulse, cellular energy ablation device, have shown the modality to be safe and potentially beneficial to prognosis. IRE to augment/accentuate the margin during pancreatic resection for certain locally advanced pancreatic cancers has not been reported. ⋯ Simultaneous intraoperative IRE and pancreatectomy can provide an adjunct to resection in patients with locally advanced disease. Long-term follow-up has demonstrated a small local recurrence rate that is lower than expected. Continued optimization in multimodality therapy and consideration of appropriate patients could translate into a larger subset that could be treated effectively.
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Many institutions now use empiric full-body computed tomography (CT) as a standard step in the initial workup of stable trauma patients. Recent data suggest that these scans may reveal unexpected injuries and improve survival in patients with polytrauma. However, patients who are unstable on presentation are often taken to the operating room (OR) without CT. Many of these patients undergo empiric full-body CTs after being stabilized in the OR, yet few data exist regarding how often early postoperative CT reveals unexpected injuries within compartments that have been explored surgically. Thus, the objective of this study was to determine if empiric abdominal/pelvic (ABD) CT after emergent trauma laparotomies are likely to reveal missed injuries requiring urgent management and improve patient management compared with clinical judgment alone. ⋯ The use of ABD CT soon after trauma laparotomy did not provide meaningful improvements in patient care in the cohort studied. Further higher level research is needed to clarify what role empiric ABD CT should play in the early postoperative period.
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Severe injury initiates an inflammatory response that can perpetuate immunological dysfunction, uncontrolled inflammation, and subsequent multisystem organ failure. MicroRNAs (miRNAs) have recently been identified as regulators of this inflammatory response. Our study sought to identify the differential expression of unique miRNAs and their correlations with genes of the Toll-like receptor (TLR) pathways, and clinical parameters in the severely injured. ⋯ Differential expression and correlations between miRNAs, genes of the TLR pathways, and clinical parameters are unique findings in the severely injured and may lead to a greater understanding of the regulation of sterile inflammation after severe injury.
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Urinary tract infections, a risk factor for readmission, have been deemed a potentially preventable problem and, therefore, not reimbursable by the Centers for Medicare and Medicaid Services since 2008. Defining the risk factors for development of urinary tract infection in the postoperative period will provide risk stratification for development of urinary tract infection in these challenging patients. ⋯ Although postoperative rates of urinary tract infection decreased after the Centers for Medicare and Medicaid Services decree, the lack of reimbursement is not justified, as few modifiable risk factors to further improve postoperative urinary tract infection rates in elderly emergency surgical patients were identified. Although targeted interventions may be developed, this complication is not easily preventable and will continue to plague acute care surgeons taking care of this challenging patient population.