One giant leapfrog for health care.

Fed up with skyrocketing health insurance costs, poor quality care and low patient satisfaction, a group of powerful benefits executives from some of the country's largest employers decided to do something about it. They formed The Leapfrog Group, a coalition of companies setting out to build a better American health care system.

Repair of sinus of Valsalva aneurysm associated with aortoventricular discontinuity.

The case of patient with unruptured sinus of Valsalva aneurysm with absence of the intervalvular lamina fibrosa is presented. The association of Valsalva aneurysm and aortic subvalvular defects has been explained as a deficiency of elastic tissue at the aortic root or maldevelopment of the fibrous trigone. Valvular aortic insufficiency with histological evidence of myxoid changes required prosthetic replacement. Myxomatous changes in the fibrous trigone and aortic annulus can explain this unusual, complex anomaly. Accurate preoperative diagnosis may require special views and simultaneous left and right injections at cineangiography. Techniques of repair that have been successful are reviewed, and the essential features of adequate correction are outlined.

Chylothorax after myocardial revascularization with internal mammary graft.

Chylothorax following an intrapericardial cardiac operation is rare, and we are aware of only 12 reported cases. Nine followed median sternotomy for treatment of congenital heart disorders or acquired valvular disease; more than expected were reoperations (23%). This report documents that this complication may also occur following myocardial revascularization with internal mammary graft and describes the anatomy that makes this possible. This rare complication is important because of the high morbidity of prolonged tube drainage and the fact that nearly half of the affected patients underwent reoperation (5 of 13). Dilated lymphatics exuding chyle have been found at operations undertaken to control lymph fistulas and were located in anterior thymic tissue previously divided by electrocautery. Awareness of the significance of lymph encountered during cardiac operations, particularly during reoperation and near the origin of the internal mammary artery, may alert the surgeon that the stage is set for a disabling complication. Electrocautery may be an unreliable means of control as lymph contains little coagulable material; suture is recommended instead.

Influence of operating room surface contamination on surgical wounds: a prospective study.

The influence of operating room contamination on wound infection rates in clean, clean-contaminated, contaminated, and septid procedures was studied by a prospective randomized study of 2,020 surgical wounds. Operating room surface contamination was assessed by the RODAC bacterial plate method. Control rooms uniformly received Wet-Vac cleaning between operations. Experimental rooms were not cleaned between consecutive clean operations, but were cleaned after contaminated operations. The difference in surface contamination between groups of experimental and control rooms was found to be significant at the P less than .05 level. Patients operated on in experimental and control rooms were followed up postoperatively to assess whether they experienced wound infection. No statistically significant differences in wound infection rates were found between experimental and control room operations as total groups, clean procedures, or operations of long duration.