Journal of the American College of Surgeons
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Clinical Trial
Toronto Management of Initially Unresectable Liver Metastases from Colorectal Cancer in a Living Donor Liver Transplant Program.
Living donor liver transplantation (LDLT) is an attractive option for patients with unresectable, bilobar colorectal liver metastases (CRLM). However, it is not available in most centers beyond study protocols. This study describes the interim experience with LDLT for CRLM at a large North American transplant and hepatobiliary center. f. ⋯ Most patients with unresectable CRLM referred for LDLT are deemed ineligible for trial inclusion. However, the excellent oncologic outcomes in patients who meet criteria for LDLT supports its role in highly selected populations. Future results after the trial's completion will inform long-term outcomes.
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The Military Health System (MHS) uses a readiness program that identifies the knowledge, skills, and abilities (KSAs) necessary for surgeons to provide combat casualty care. Operative productivity is assigned an objective score based on case type and complexity and totaled to assess overall readiness. As of 2019, only 10.1% of surgeons met goal readiness threshold. At one tertiary military treatment facility (MTF), leadership has taken an aggressive approach toward increasing readiness by forming military training agreements (MTAs) and allowing Off Duty Employment (ODE). We sought to quantify the efficacy of this approach. ⋯ Increased use of MTAs and ODE significantly augments average caseloads. These operations provide considerable benefit and result in surgeon readiness far exceeding the MHS average. Military leadership can maximize the chances of meeting readiness goals by encouraging clinical opportunities outside the MTF.
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Although postoperative opioid overprescription has been well studied, little is known about opioid underprescription. This study aims to determine the extent of improper discharge opioid prescription in patients undergoing general surgery procedures. ⋯ Although avoiding postoperative opioid overprescription remains imperative, preventing postoperative opioid underprescription is also essential. We recommend using a patient-centered approach to match the daily dose of opioid prescription with each patient's inpatient daily opioid consumption.
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Acute traumatic coagulopathy (ATC) has many phenotypes and varying morbidity and mortality. The MA-R ratio, calculated from the admission thromboelastogram, serves as a biomarker to identify 1 phenotype of ATC and has previously been associated with significant derangements in the inflammatory response. This study evaluates outcomes related to abnormal MA-R ratios, including inflammatory responses, in a heterogeneous patient population. ⋯ The subtype of ATC identified by the low MA-R ratio is associated with significant elevations in multiple proinflammatory cytokines at admission. Early mortality remains elevated in the CRITICAL group, in part due to coagulopathy. The MA-R ratio at admission is associated with a particularly morbid type of coagulopathy, associated with significant alterations in the inflammatory response after severe injury in heterogeneous patient populations.