Operative acute small bowel obstruction: admitting service impacts outcome.

Early surgical intervention in acute small bowel obstruction (SBO) has long been recognized as an important factor in preventing morbidity and mortality. Factors associated with surgically managed acute SBO were analyzed for delay in intervention and impact on outcome. A retrospective review of all patients evaluated for SBO on the surgical teaching service of the Greenville Hospital System from July 1, 1997 to June 30, 2000 was performed. Data were collected on patient demographics, admission information (date, admitting service, physical examination, and laboratory values), comorbidity, diagnostic studies, surgery date, operative findings, postoperative complications, operative mortality, and discharge date. Analysis of the data revealed 157 cases of presumed SBO of which 61 were managed nonoperatively and 96 required surgery. Acute SBO was diagnosed in 65 patients who constitute the basis for this review. Of these 65 patients 43 (66%) were admitted to the surgical service, 25 (38%) required small bowel resection, and 17 (26%) developed morbidity and/or mortality. When analyzed for morbidity and mortality the only characteristics that were statistically significant were the admitting service (P = 0.003) and length of stay (P = 0.003). On further analysis of admitting service and patient outcomes several factors were significant when we compared medical service admissions to surgical service admissions. These included days from admission to surgery (P = 0.003), length of stay (P = 0.019), morbidity (P = 0.004), mortality (P = 0.005), and combined morbidity and mortality (P = 0.003). Mortality of patients admitted to the medical service was 27 per cent compared with 2 per cent for the surgical service. There were no differences in morbidity and mortality when analyzed by the need for small bowel resection, patient age, etiology of obstruction, or presence of comorbidities. None of the factors studied were useful in predicting the need for small bowel resection. Our findings agree with those of previous investigators with regard to 1) lack of association between the preoperative evaluation and the need for small bowel resection and 2) the association between delay in diagnosis and increased morbidity and mortality. In addition we have found that one of the primary causes of delay in treatment for SBO was admission to the medical service. This delay led to significantly higher mortality in these patients. We recommend early surgical evaluation for any patient admitted with SBO as a differential diagnosis.

Isolated arteriovenous dialysis access graft segment infection: the results of segmental bypass and partial graft excision.

Arteriovenous (AV) access graft infection results in disruption of dialysis and usually necessitates graft removal when the entire graft is involved. The management of an isolated infected segment of an otherwise noninfected AV access graft, however, remains controversial. To evaluate the utility of segmental bypass and partial graft excision for the treatment of an isolated infected AV access graft segment, 17 consecutive cases in 12 patients (7 females/5 males; 14 arm grafts/3 leg grafts; median age = 69 years) were analyzed on a vascular teaching service that performed 1244 total access procedures from January 1995 through February 1999. Infections presented as a draining sinus or a sinus with hemorrhage emanating from an area over the graft. At operation, the infected sinus was covered by a transparent occlusive dressing and the graft was explored through clean incisions proximal and distal to the infected segment. If the graft was incorporated and free of infection, a piece of expanded polytetrafluoroethylene (ePTFE) was anastomosed proximally end-to-end and tunneled through noninfected tissues around the infected sinus. After the distal anastomosis was performed, the skin incisions were closed and covered with occlusive dressings. The infected graft segment was then removed through the infected sinus wound. The technique of segmental bypass and partial graft excision results in predictable eradication of infection, graft salvage, and maintenance of uninterrupted dialysis in patients presenting with an isolated AV dialysis access infection.

Marketing dental implants: a step-by-step approach.

Introducing dental implants into a practice requires planning and commitment. Part of the planning process is learning new clinical skills, but another essential component is developing a marketing approach. The author offers a seven-step plan for adding dental implants to your repertoire.

Pay satisfaction: its multidimensional nature and measurement.

The present study was guided by the general hypothesis that pay satisfaction is multidimensional. The Pay Satisfaction Questionnaire (PSQ) was developed to assess five dimensions of satisfaction with pay (level, benefits, raises, structure, and administration). Results on two heterogeneous samples of employees provided support for the multidimensional hypothesis, although a four-dimensional solution (level, benefits, raises, structure/administration) provided better representation of the variance in the items studied. These four scales showed high internal consistency reliabilities. Comparison of the pay scales of the Job Descriptive Index and Minnesota Satisfaction Questionnaire with the PSQ dimensions suggested that these well-known scales primarily measure satisfaction with pay level. Implications of the findings for pay satisfaction research, both substantive and measurement oriented, are discussed.