Articles: surgery.
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Epidural anaesthesia is used extensively for cardiothoracic and vascular surgery in some centres, but not in others, with argument over the safety of the technique in patients who are usually extensively anticoagulated before, during, and after surgery. The principle concern is bleeding in the epidural space, leading to transient or persistent neurological problems. ⋯ These estimates for cardiothoracic epidural anaesthesia should be the worst case. Limitations are inadequate denominators for different types of surgery in anticoagulated cardiothoracic or vascular patients more at risk of bleeding.
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When patients are asked what they find most anxiety provoking about having surgery, the top concerns almost always include postoperative nausea and vomiting (PONV). Only until recently have there been any published recommendations, mostly derived from expert opinion, as to which regimens to use once a patient develops PONV. The goal of this study was to assess the responses to a written survey to address the following questions: 1) If no prophylaxis is administered to an ambulatory patient, what agent do anesthesiologists use for treatment of PONV in the ambulatory Post-Anesthesia Care Unit (PACU)?; 2) Do anesthesiologists use non-pharmacologic interventions for PONV treatment?; and 3) If a PONV prophylaxis agent is administered during the anesthetic, do anesthesiologists choose an antiemetic in a different class for treatment? ⋯ 5-HT3-antagonists are the most common choice for treatment of established PONV for outpatients when no prophylaxis is used, and also following prophylactic regimens that include a 5HT3 antagonist, regardless of the number of prophylactic antiemetics given. Whereas 3%-7% of anesthesiologists would repeat dose metoclopramide, dexamethasone, or droperidol, 26% of practitioners would re-dose the 5-HT3-antagonist for PONV treatment.
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There have been few studies to date that investigate the effect of race on outcomes related to coronary artery bypass grafting. The objective of the present study was to investigate race as an independent predictor of outcomes among patients undergoing coronary artery bypass graft (CABG). A nested case-control study from a twelve-year hospitalization cohort (N=9671) in which data were collected prospectively was conducted. ⋯ Multivariate analysis revealed African-Americans were at greater risk for renal complications (OR 1.88, 95% CI 1.27-2.77), neurological complications (OR 1.34, 95% CI 1.01-1.77), and pulmonary complications (OR 2.11, 95% CI 1.72-2.59). African Americans had a significantly longer hospitalization post-operatively (OR 0.79, 95% CI 0.66-0.96), but were less likely to experience post-operative atrial fibrillation requiring treatment than Caucasians (OR 0.64, 95% CI 0.49-0.84). Even after multiple adjustments, African-Americans undergoing CABG surgery had significantly greater morbidity compared to Caucasian patients.
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Computer-assisted neurosurgery has become so successful that it is rapidly becoming indistinguishable from, quite simply, neurosurgery. This trend promises to accelerate over the next several decades, bringing considerable benefit to the patients we care for. From a pragmatic point of view, can we identify specific instances in which clinical practice has been altered by computer assistance? During craniotomies for the resection of brain tumors, this technology has led to a greater standardization within and among practitioners for the expected degree of resection and the risk of morbidity and mortality. ⋯ It is apparent that using computer assistance in neurosurgery has begun a process that will irrevocably transform all of neurosurgical practice itself. It must be neurosurgeons themselves who provide the leadership to transcend the potentially distracting aspects of this technological revolution. What shall not change is the commitment that we, as neurosurgeons, have to the welfare of our patients.
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Multicenter Study Comparative Study
Image-guided resection of high-grade glioma: patient selection factors and outcome.
In patients with glioma, image-guided surgery helps to define the radiographic limits of the tumor to maximize safety and the extent of resection while minimizing damage to eloquent brain tissue. The authors hypothesize that image-guided resection (IGR) techniques are associated with improved outcomes in patients with malignant glioma. ⋯ Selection bias occurs regarding patients who receive IGR; these biases include younger age, presentation with seizure and normal level of consciousness, tumor diameter less than 4 cm, and non-GBM on histopathological studies. Outcome appears to be improved in patients who undergo IGRs of high-grade gliomas. It is unclear if these improved outcomes are due to the selection of a more favorable patient population or to the IGR techniques themselves. It is likely that the full potential of image guidance in glioma surgery will not be realized until it is applied to a wider range of patients.