American journal of surgery
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Operative mortality after repair of even the most complex congenital heart lesions has become rare. As such, the gaze of the surgical team has been diverted beyond that of early survival to focus on decreasing early and late morbidity. Important and concerning information is accumulating delineating the vulnerability of the neonatal brain to injury as the result of congenital heart disease and/or the techniques employed to correct the lesions. ⋯ It is yet undetermined whether these strategies will translate into improved short- and long-term neurologic outcome. Common to all surgical disciplines is a trend that as mortality decreases for a particular disease process, focus is adjusted, and refinements in treatment protocols are designed to minimize morbidity of the disease and its treatment. This natural refining process of a discipline's maturation is increasingly present in the field of congenital heart surgery.
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Diabetes mellitus affects 5-10% of the US population at some point in their lives. Hyperglycemia produces serious chronic complications. ⋯ Secondary infection of these ulcers is by far the leading cause of major amputations of feet and legs. Proper preventative care will dramatically reduce ulcer formation and costs related to this complication.
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Despite recent significant improvement in outcome, children undergoing surgery for correction of congenital heart defects have a persistent and troublesome mortality rate and incidence of neurologic complications. Recent data suggest that some congenital heart defects are associated with abnormal brain development and with low cerebral blood flow. We hypothesized that some children with congenital heart disease have an abnormally low baseline (preoperative) cerebral oxygen saturation (ScO2). ⋯ Baseline ScO2 is lower in patients with left-to-right shunt physiology. Postoperative saturation is lower in patients with left-to-right shunt physiology and in cyanotic patients. Low baseline ScO2 predicts perioperative mortality in children with congenital heart disease. Measurement of ScO2 preoperatively will provide additional information for parent counseling, and preoperative optimization of ScO2 may improve outcome.
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Comparative Study
Formal training in advanced surgical technologies enhances the surgical residency.
Surgeons have been consistently instructed to use better tools by which to improve upon a patient's medical care. Since the first laparoscopic cholecystectomy, the desire for advanced surgical technologies has continued. This surgical breakthrough has been one of many changes in modern surgical and medical therapy that now represents the standard of care. The aim of this article is to examine the changes in surgical technologies that occurred in the past 15 years, evaluate the possible solutions that have been discussed and formally present the results of a formal training rotation in advanced surgical technologies at the University of Louisville, Department of Surgery. ⋯ The number of demands impacting medical education have never been this numerous or complex. The rapid advances in science, systems, and information technology provide numerous advances in surgical training that continue to be the requirement and responsibility of general surgical training. The cultural changes in surgery include the team approach to provide services in surgical technologies, focus on the aging population, and outcomes assessment. The learning curve, for any and all of these procedures, is inevitably steep, and traditional resident training too often focuses on the more conventional procedures done in routine rotations. The need for formal training in advanced surgical technologies continues to be of utmost importance in these rapidly evolving times.
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Decompensated hemorrhagic shock is often refractory to resuscitation, and we show here that it is associated with loss of vascular tone in skeletal muscle precapillary arterioles. We tested the hypothesis that microvascular derangements in the skeletal muscle, intestinal, and renal microcirculation systems would be reversed by initial hypertonic saline-dextran infusion. ⋯ Despite return of cardiac output to greater than baseline levels, muscle, intestinal, and renal microvascular blood flows remained significantly depressed. Hypertonic saline and/or dextran did not improve these deficits.