Feasibility of damage control surgery in the management of military combat casualties.

Unique and expanded applications of staged operative management are undergoing careful evaluation in many civilian level I trauma centers under the rubric of damage control surgery. Recently there have been advocates for its broad application to the early management of critically injured combat casualties. However, the enormous logistic requirements for such strategies are contrary to the demands of the usual wartime scenario. On the basis of experience in civilian trauma centers and combat casualty management, we question the suggested extensive role of damage control surgery during wartime. Each decision point in damage control surgery should be analyzed as it is altered (sensitivity analysis) by conditions of war. It is unwise to adopt such indications unchanged from current civilian trauma policy.

Government-provided health care. A prediction.

Government-provided health care, provided primarily by the Department of Veterans Affairs and the Department of Defense, must prove itself competitively cost-effective for its continued survival. Cooperation and unification of health programs at each level of government are essential to minimize uneconomic duplications. Some form of a managed-care HMO will be necessary for future health care programs of the Department of Veterans Affairs and the Department of Defense. Enrollees must include the spouses and dependents of veterans. Each population segment of government-provided care should undergo a make-or-buy analysis to guide cost-effective strategies. A voucher system should be instituted on an experimental basis to explore the transition between the current system of health care and alternative use of community-based private care. Such a system has the political advantage of taking away nothing from the current rights of veterans or retirees. A variety of joint ventures between government health systems and private sector HMOs have been described. Cost cannot be the only consideration in make-or-buy government decisions. Overriding national priorities of defense, training of future physicians, and scientific advancement must also be considered.

[Perioperative blood transfusions. Changed indications and new alternatives]. / Perioperative Bluttransfusionen. Veränderte Indikationen und neue Alternativen.

The surgeon has to keep abreast of changing advantages and disadvantages as well as alternatives in the context of homologous blood transfusions. We ought to realise that normovolaemic anaemia is better tolerated than we used to assume in the past. It is no longer necessary to provide transfusions to patients with 10 g/% Hb. About 8 g/% should rather be considered the adequate threshold. Possible transmission of hepatitis and AIDS virus is a genuine risk associated with blood transfusion. No hard evidence has yet been produced to immunosuppression and effects on the prognosis of cancer patients. More attention will have to be given in the future to preoperative supply of blood for autohaemotherapy.

Cost-effective diagnostic test sequencing.

Proper diagnostic test selection and logical sequencing can minimize cost without compromising care. This study analyzes the logic for sequencing tests either in series (one after another) or in parallel (simultaneously). A model is created using 2 diagnostic tests for 2 diseases. Tests are assumed to have perfect performance characteristics. Factors involved in cost-effective test sequencing include cost of each test, test performance characteristics, per diem hospital charge, and the clinician's prior probability of the suspected diagnosis based on history, physical examination, and previous laboratory data. At a given point of clinical suspicion, cost-effective sequencing strategy should shift. In general, a cheap test can effectively be used in parallel even at low diagnostic probabilities; an expensive test should, in general, be used in series only when there is a high prior probability of diagnosis. High per diem hospitalization costs--such as for a patient in the intensive care unit--favor in parallel testing. Clinical acumen and suspicion of diagnosis (prior probability) primarily direct cost-effective diagnostic test sequencing. Decision analysis of diagnostic test sequencing represents a technique for making cost-effective decisions for sequencing and, thereby, minimizing costs while achieving optimal patient care.

Cost-effective follow-up of the cancer patient. Time for a new look.

Physicians are increasingly aware of their complex responsibilities in finding the difficult compromise necessary to achieve cost-effective follow-up care of cancer patients. They must consider not only the best interests of their patients but also the interests of a cost-conscious society. To meet their new societal obligations, physicians trained solely to serve the patient's best interest must now learn how to do so at the least expense. This implies knowing both the costs and the performance characteristics of the diagnostic tests ordered in follow-up. The authors analyze this dilemma as it applies to follow-up of patients following primary treatment for colon cancer or nonseminomatous testicular cancer. Principles of cost-effective patient management are reviewed.

[Immune depression as a reaction to surgical operations--its significance for postoperative infection]. / Die Immundepression als eine Reaktion auf Operationen--Ihre Bedeutung für postoperative Infektionen.

Injuries, burns, and surgical intervention may lead to temporary depression of immune defence. Today, life-threatening infections may be caused by bacteria, such as pseudomonas, bacteroids, serratia as well as by viruses, including cytomegaly virus, and yeasts. Severe infections of that kind may be countered by adequate nutrition, planned application of antibiotics or, in the future, by possible active substances against depression of the immunity system, such as interferone, interleucine, and prostaglandins. More attention should be given in surgery to control of immunological defence as well as to knowledge about immunological defence mechanisms. Immune defence has proved to play an important role not only in transplantation surgery but also in other major surgical interventions and in intensive therapy.

Development of a new vascular prosthetic: lessons learned.

In 1972, polytetrafluoroethylene (PTFE) (GoreTex) wire insulation was first implanted into arteries and veins of dogs at the University of Colorado Health Sciences Center in Denver. Subsequent modifications including fibrillar arrangement, wall thickness, and pore size led to the development of a vascular prosthesis with tissue ingrowth, viable neointima, and encouraging patency rates. Tissue culture, surface charge, and platelet studies have all demonstrated the optimal biologic qualities of PTFE grafts. Replacement of one human portal vein by a PTFE graft for invasive carcinoma of the pancreas was strikingly successful. Only unexplained intimal hyperplasia at the arterial anastomotic margins discouraged us from extensive early clinical trials.

The role of electron microscopy in the management of surgical patients.

This report records a 12-month experience with 49 neoplasms submitted to the hospital pathologists for electron microscopic (EM) diagnosis as a part of routine clinical surgical practice. Twenty-five specimens were from a private community hospital and 24 from a university hospital. In 40 of 49 cases (82%), EM confirmed a tentative light microscopic (LM) diagnosis. In 11 of these 40 cases, EM provided a more specific histogenetic diagnosis than was possible by LM. In three cases (6%), EM corrected the original LM diagnosis. In two cases EM did resolve a diagnostic dilemma. EM is a beneficial adjunct to the correct diagnosis of selected tumors. Although in general EM does not help differentiate benign from malignant tumors, it is helpful in identifying the cell of origin of poorly differentiated neoplasma. A more precise histogenetic diagnosis was judged to be clinically helpful in 56% of th cases studied in this experience. EM is a relatively inexpensive ($115-250) and prompt (three to five days) adjunct to surgical care. It should be routinely available to the practicing surgeon for help in determining the cell type of confusing tumors. EM is no longer simply a research tool.