The Surgical clinics of North America
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Surg. Clin. North Am. · Feb 1996
ReviewQuality assurance and medical outcomes in the era of cost containment.
Market forces are driving health care organizations to "prove" quality while diminishing costs. Payers for health care, led by large employers and insurance companies, are demanding clinical, financial, and satisfaction outcomes from providers. To meet the challenge, traditional quality assurance based on inspection and rooting out "bad apples" is rapidly being replaced by the industrial engineering principles of continuous quality improvement. ⋯ Professional societies have collaborated in the development of clinical guidelines and outcomes data bases. This massive reorganization will take several more years to play out. With careful development it has the potential to dramatically improve patient care through the efficient application of new scientific knowledge and the sustained flow of information back to physicians and patients.
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Surg. Clin. North Am. · Feb 1996
ReviewThe influence of surgical training on the practice of surgery. Are changes necessary?
Changes in health care financing are having a significant effect on surgical practice. These changes require adjustments in what surgical trainees must learn as well as where and how they must learn. To ensure educational quality, surgical educators must have a clear definition of their educational mission.
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The presence of a substernal goiter is an indication for thyroidectomy, even in asymptomatic patients, because there is no other effective method of preventing growth of the goiter. Both primary and secondary substernal goiters usually exhibit slow but steady growth, which leads to tracheal, esophageal, vascular, and neurologic compression syndromes. Airway obstruction, which poses a life-threatening situation, may be suddenly precipitated by spontaneous or traumatically induced bleeding into the substernal goiter, as well as by tracheal infections. ⋯ Morcellization or fragmentation of the goiter is less desirable because of the possibility of dissemination of potential malignancies within the goiter. Primary intrathoracic goiters, recurrent goiters, and malignant goiters often require a median sternotomy for safe removal. The recurrence rate of goiters after surgical removal is low.
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Surg. Clin. North Am. · Apr 1995
ReviewCurrent concepts in the use of cavitary endoscopy in the evaluation and treatment of blunt and penetrating truncal injuries.
The use of thoracoscopy in the patient with penetrating injury to the thorax is in its infancy. Although it is used mainly for diagnosis, evidence suggests that it will become a therapeutic tool during the initial management of the traumatized patient and in the postinjury period (early evacuation of retained hemothorax and the treatment of empyema). Although its role in injuries to the superior chest is clear, its role has not been established in the evaluation of the diaphragm. ⋯ Further studies help define the place of these procedures for injuries in the thoracoabdominal area. The indications for cavitary endoscopy after truncal injury are summarized in Table 2. It must be remembered that experience in this field is rapidly increasing, and indications will change with new studies and new technology.
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Aneurysmal subarachnoid hemorrhage in a pregnant woman is a rare catastrophic situation that places both the mother and the fetus at high risk. When this situation arises, numerous relevant issues must be individualized in the effort to reduce hazards threatening both the mother and the fetus. These issues have been addressed in terms of the published experience and in terms of modern obstetric, anesthetic, and neurologic surgery technology.