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To the Editor We read the article by Sieber et al with great interest. Postoperative delirium (PD) is an increasing problem and one of the least well-understood problems today. Whether general anesthesia leads to PD that in turn leads to or unmasks dementia (Alzheimer disease) is the bigger question, as referred to in the Editorial accompanying this article. Sieber et al hereby fail to prospectively find an association of PD with depth of anesthesia. Within its limitations, on the one hand, this reassures us of the safety of use of anesthetics in older patients; on the other hand, this once again reinforces our belief that PD has a more complex etiopathology than we understand to date. Despite controlling for most factors (Table 1), what st.
In Reply We appreciate the comments by Pal and understand the quandary in trying to generalize our study. Pal’s comments concerning age, surgery risk, type of anesthetic drug, or phenotype certainly point to the evidence that postoperative delirium is a complicated geriatric syndrome and that many factors weigh into its causation. Many of the factors mentioned should be the focus of future studies in this area to help enhance our understanding and improve management. From our study design, we cannot comment on surgical risk or other anesthetic drugs. However, in this randomized clinical trial, in an older population undergoing hip fracture repair, lighter propofol sedation was not found to decrease the incidence of postoperative delirium ex.
Postoperative cognitive impairment has been challenging to define given the varied cognitive tests used across previous studies. Also, earlier literature is unclear whether exposure to an operation, often using ill-defined surgical and anesthesia factors without nonoperative controls, played an independent role in long-term cognition. However, the momentum of current evidence is that preoperative patient features (eg, educational level, employment) and critical neurologic events during hospitalization (eg, delirium) independently influence long-term cognition. Operation alone does not appear to influence long-term cognition. So, we read with great interest this work by Austin et al, published in this issue of. JAMA Surgery. , that evaluated 1.
In an effort to increase the value of care, the US Centers for Medicare and Medicaid Services (CMS) committed to changing 50% of its Medicare reimbursement to alternative payment plans by 2018. One strategy included the introduction of outcome-based pay-for-performance. As of fiscal year 2018 (October 2017), the approach included metrics for complications and mortality (Hospital Value-Based Purchasing Program and Hospital Acquired Condition Reduction Program) and readmissions (Hospital Readmissions Reduction Program [HRRP]). Within the HRRP, payments to hospitals are determined based on performance on 6 condition-specific metrics. Four address internal medicine hospitalizations for acute myocardial infarction, heart failure, pneumonia, and
Guidelines from the Society for Vascular Surgery and the American Heart Association/American Stroke Asssociation recommend carotid endarterectomy (CEA) for asymptomatic carotid artery stenosis if a patient’s minimum life expectancy is 3 to 5 years. An estimated 20% of CEAs for asymptomatic carotid stenosis are performed in patients with life-limiting conditions. Given the rapidly aging surgical patient population in the United States, it is imperative that surgeons have the tools to adequately identify patients who will benefit from surgery.
In the article titled "New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults," published online April 12, 2017, in. JAMA Surgery. , it was discovered that the indicators for presurgical diagnoses of mental and physical health conditions were actually indicators for these conditions at any point 1 year prior to surgery (the defined preoperative period in the article) to 1-year postsurgery.
In Reply We thank Pendharkar et al for their comments regarding our article. As noted, reducing the number of computers on wheels (COWs) was associated with fewer communication barriers. While we agree that using the right technology may improve health care, the electronic medical record (EMR) in its current platform is a disruptive technology that requires improvement. The EMR should better adapt to its users by optimizing human factors technology rather than forcing the user to adapt to the EMR. We agree that the data derived from the EMR are necessary and often provide more information than the traditional medical record, but the platform through which they are currently delivered is suboptimal.
To the Editor The recent study by Dhillon et al suggests that using computers on wheels (COWs) during rounds detracts from patient communications. Furthermore, it was stated that removing computers could restore communications. We assert that in an increasingly data-driven health care system, using the right technology and having access to electronic health record (EHR) data during rounds is critical, even life-saving.
Access to, and the provision of, specialized post–short-term care services are critical components of the trauma care continuum aimed at maximizing optimal functional recovery and quality of life for patients with injuries. The association between insurance status and access to rehabilitation services is well documented. Families with low incomes, underrepresented minorities, those with limited English proficiency, and the uninsured face significant barriers in the availability and proximity of outpatient rehabilitation services. The reality is that economic and financial incentives may outweigh medical need and necessity. The Affordable Care Act (ACA) and its provisions were designed to improve access to care through improved insurance cov.
Bariatric surgery is the most effective option to treat obesity and associated health consequences. However, as obesity is a progressive condition and technical problems may happen after bariatric interventions, revisional surgery needs to be part of an escalation of therapy or correction after any postoperative technical issue, as already established after some other interventions, such as in oncology, arthroplasties, and heart surgery. Bariatric revisional surgery numbers are increasing. However, most of the published studies are small and cover less than 5 years of follow-up. Moreover, choosing the best primary procedure may determine the chances of long-term success and consequently affect the possibility of surgical revisions.

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