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Biomedical subjects

Lazar J Greenfield

Publications and source records attributed to Lazar J Greenfield.

At least 19 recordsLinked to original sources
PubMed2006

Medical liability-the crisis, the reality, and the data: the University of Michigan story.

BACKGROUND: This study describes, quantifies, and evaluates the University of Michigan Department of Surgery medical malpractice experience for the 1992 to 2002 period. The goal is to gain an understanding of what our claims experience has been, what services are highest risk, and where the financial exposure lies. STUDY DESIGN: The study analyzed 308 medical malpractice cases within the Department of Surgery from 1992 through 2002. RESULTS: There were 263 cases involving a single surgical service (defendant-only) and 70 shared cases involving multiple services. One hundred forty-four cases (47%) were settled with no payment to the plaintiff. Settlements for all cases totaled Dollars 38,718,254. The per-case expense (not including legal fees) was Dollars 125,708. Legal expenses for all cases totaled Dollars 5,356,588, averaging Dollars 17,391 per case. CONCLUSIONS: Understanding and sharing institutional data on medical malpractice is critical to developing effective strategies for managing malpractice risk. Although many institutions treat these data as proprietary and confidential, communication of this information generates a better understanding of the opportunities that are available for development and implementation of appropriate risk-management tools.

Hospitals, University↗
PubMed2006

Surgeon age and operative mortality in the United States.

OBJECTIVES: Although recent studies suggest that physician age is inversely related to clinical performance in primary care, relationships between surgeon age and patient outcomes have not been examined systematically. METHODS: Using national Medicare files, we examined operative mortality in approximately 461,000 patients undergoing 1 of 8 procedures between 1998 and 1999. We used multiple logistic regression to assess relationships between surgeon age (< or =40 years, 41-50 years, 51-60 years, and >60 years) and operative mortality (in-hospital or within 30 days), adjusting for patient characteristics, surgeon procedure volume, and hospital attributes. RESULTS: Although older surgeons had slightly lower procedure volumes than younger surgeons for some procedures, there were few clinically important differences in patient characteristics by surgeon age. Compared with surgeons aged 41 to 50 years, surgeons over 60 years had higher mortality rates with pancreatectomy (adjusted odds ratio [OR], 1.67; 95% confidence interval [CI], 1.12-2.49), coronary artery bypass grafting (OR, 1.17; 95% CI, 1.05-1.29), and carotid endarterectomy (OR, 1.21; 95% CI, 1.04-1.40). The effect of surgeon age was largely restricted to those surgeons with low procedure volumes and was unrelated to mortality for esophagectomy, cystectomy, lung resection, aortic valve replacement, or aortic aneurysm repair. Less experienced surgeons (< or =40 years of age) had comparable mortality rates to surgeons aged 41 to 50 years for all procedures. CONCLUSIONS: For some complex procedures, surgeons older than 60 years, particularly those with low procedure volumes, have higher operative mortality rates than their younger counterparts. For most procedures, however, surgeon age is not an important predictor of operative risk.

Adult↗
PubMed2006

A role for interleukin-10 in the assessment of venous thromboembolism risk in injured patients.

BACKGROUND: Management of patients with multiple trauma requires prophylaxis for venous thromboembolism (VTE). This involves recognition of the physiologic factors that are associated with VTE risk. Currently, there is no effective strategy for risk assessment. The purpose of this study is to investigate the relationship of serum P-selectin and interleuken-10 (IL-10) with VTE as a possible physiologic marker. METHODS: Patients admitted to two trauma centers with an Injury Severity Score >/=9 had blood samples drawn and underwent duplex ultrasound scanning of the lower extremities before initiating prophylaxis at admission, on days 3 and 7, and weekly until discharge. Patients were prophylaxed according to institutional protocols. RESULTS: One hundred eighty-six patients were enrolled with a VTE incidence of 17.8%. The population was predominantly male (60%), with a mean age of 48 years. sP-selectin levels were not statistically different between the groups (64.4 versus 74.8 pg/mL). However, IL-10 was significantly lower in the VTE group at both the initial and subsequent blood draws (21 versus 165 ng/mL, p = 0.012). Further, the ratio of sP-selectin to IL-10 (3.92 versus 0.92, p = 0.014) was statistically higher in the VTE group at admission. CONCLUSION: An elevated sP-selectin to IL-10 ratio appears to be associated with the development of VTE in patients at high risk and may prove to be a useful clinical marker for this dreaded complication among trauma patients. Early recognition of this high-risk group improves the accuracy of the risk/benefit determination for prophylaxis and identifies a group in whom routine ultrasound screening would be cost-effective.

Female↗
PubMed2005

Thoracic outlet decompression for subclavian vein thrombosis: experience in 71 patients.

HYPOTHESIS: There is a difference in outcomes when patients have neurogenic thoracic outlet syndrome in addition to subclavian vein thrombosis. METHODS: Analysis of a prospectively developed database, medical record review, and a patient questionnaire were used to summarize clinical experience from December 1990 to December 2001 on the basis of the patient's original evaluation. Patients were stratified on the presence (group 1) or absence (group 2) of additional neurogenic pathologic features. RESULTS: Of 928 patients evaluated for thoracic outlet syndrome, 71 underwent 73 operative procedures for subclavian vein obstruction. Men predominated (55%), and the mean age was 32 years. Group 1 (41%) had more preoperative disability, a higher incidence of persistent pain (24%), and less likelihood of returning to full activity compared with group 2 (67% vs 93%; P = .01). Catheter-directed thrombolysis was used in 65% of veins. Preoperative balloon angioplasty was used selectively (34%), and only 4% required stents. Supraclavicular decompression and venolysis were usually delayed 3 weeks to allow for healing of the venous endothelium. Complications included wound infection (3%) and postoperative hematoma (8%). CONCLUSIONS: Patients with isolated subclavian vein obstruction have a more favorable outcome relative to those with combined neurogenic and venous pathologic features. Decompression following thrombolysis should be delayed to reduce the incidence of postoperative complications.

Adult↗
PubMed2005

Osteomyelitis of the foot and toe in adults is a surgical disease: conservative management worsens lower extremity salvage.

OBJECTIVE: To characterize the national epidemiology of adult osteomyelitis (OM) and, using a single institutions' experience, test the hypothesis that early surgical therapy as compared with antibiotics alone results in an improved chance of wound healing and limb salvage. BACKGROUND: Foot and digit OM is a very common problem for which management is variable and for which few guidelines exist. METHODS: The Nationwide Inpatient Sample (NIS) and a single institution review from 1993 to 2000 form the basis of this study, using ICD-9CM codes for lower extremity foot and digit OM. Demographics, risk factors, and treatments were analyzed against the outcomes of a healed wound, limb salvage, and death. RESULTS: The NIS included 51,875 patients (incidence = 9/10,000 patients per year) with a mean age of 60 years, and 59% were men. The median length of stay decreased from 9 to 6 days (P < 0.001), but the average admission charge of 19,000 dollars did not significantly decrease over 7 years. Of these patients, 23% underwent a digit amputation and 8.5% suffered proximal limb loss. Single-institution analysis of 237 consecutive patients with OM confirmed a similar mean age (58 years), gender (67% men), and most presented with a foot or digit ulcer (56%). Wound healing was achieved in 56% and overall limb salvage was 80%. Decreased wound healing was associated with peripheral vascular occlusive disease (odds ratio, 0.4; 95% confidence interval, 0.2-0.8, P = 0.006) and preadmission antibiotic use (odds ratio, 0.2; 95% confidence interval, 0.05-1.1, P=0.07), while surgical debridement (odds ratio, 2.2; 95% confidence interval, 1.2-4.2, P = 0.02) was associated with increased healing. Limb salvage was improved with an arterial bypass (odds ratio, 3.9; 95% confidence interval, 1.1-14, P = 0.04), while preadmission solid organ transplant (odds ratio, 0.37; 95% confidence interval, 0.14-0.96, P = 0.04), peripheral vascular occlusive disease (odds ratio, 0.25; 95% confidence interval, 0.12-0.5, P = 0.001), and preadmission antibiotic use (odds ratio, 0.34; 95% confidence interval, 0.15-0.77, P = 0.009) were associated with greater limb loss. CONCLUSION: Digit OM is an expensive and morbid disease. Aggressive surgical debridement/digit amputation and selected use of arterial bypass should improve wound healing and limb salvage, respectively. In contrast, antibiotic therapy alone is associated with decreased wound healing and limb salvage.

Aged↗
PubMed2004

Diagnosis of pulmonary embolism with various imaging modalities.

Pulmonary embolism (PE) is a major health concern that affects approximately 600,000 new patients annually. The diagnosis of PE can be difficult to make, and several imaging studies have been developed to aid in this process. Initial evaluation involves the acquisition of a chest radiograph. Findings on radiography, however, are often non-specific. The gold-standard study historically has been pulmonary angiography, with increasing diagnostic yield since the implementation of digital subtraction technology. This is an invasive procedure, however, but the incidence of major complications is low. Less invasive modalities have been developed and include ventilation-perfusion lung scans. These are used as one of the initial screening tests in evaluation of patients with suspected PE. The presence of a high-probability scan usually indicates the presence of a PE, although few patients have high probability scans. The test is significantly affected by underlying pulmonary disease or previous PE. Given this, ventilation-perfusion lung scans are limited as a primary diagnostic tool in the evaluation of suspected PE. Helical computed tomography (CT) is currently under much scrutiny as a diagnostic tool for PE. Currently a prospective, multicenter trial evaluating its efficacy (PIOPED II) has been initiated, but the results are pending. Preliminary reports suggest the helical CT and venous phase CT may become a first line study in patient evaluation. The diagnosis of PE is challenging and several imaging modalities are currently used to assist the clinician. Currently, multiple modalities are often required to make the diagnosis. With the advent of new technology and improved imaging techniques, the diagnosis of PE will become easier.

Humans↗
PubMed2003

Vena caval filter use in patients with sepsis: results in 175 patients.

BACKGROUND: Septic patients are at risk of thromboembolism. However, the Food and Drug Administration guidance for intravascular filters states that "filters should not be implanted in patients with risk of septic embolism." The purpose of this study is to evaluate this restriction. HYPOTHESIS: There is no difference in outcomes following filter placement in patients with and without septicemia. DATA SOURCES: A registry of vena caval filter experiences containing information regarding filter placement and annual examinations of more than 2600 patients obtained during a 15-year period was reviewed. We conducted a MEDLINE search of publications reporting clinical sequelae of filter placement in septic patients. DATA EXTRACTION: The registry was searched for patients with a diagnosis of sepsis at filter placement; survival rates, adverse events, and recurrent sepsis or thromboembolism were noted. The MEDLINE search joined results from 7 MeSH headings (vena cava filter,sepsis, septic thromboembolism, vena caval filter contraindication, and filter adverse events) related to filters and sepsis. DATA SYNTHESIS: One-hundred seventy-five patients (6.7%) met the criteria and received Greenfield filters. None of the adverse events were related to sepsis, and no filter was removed. Follow-up data were available for 56 patients, with a combined recurrent pulmonary embolism and caval occlusion rate of 1.7%. The 30-day mortality rate was 33%. We noted a significant difference in survival related to the use of anticoagulation therapy (P =.001) and to age (P =.004). The MEDLINE search did not identify any clinical reports of septic filters or the need to remove a filter because of sepsis. CONCLUSIONS: Based on our review, the Greenfield filter is a safe method of prophylaxis for septic patients. Rescinding the restriction for use of vena caval filters in septic patients should be considered by regulatory bodies.

Adolescent↗
PubMed2003

Limiting resident duty hours.

Limitation of resident duty hours continues to be a national concern with weekly work hour limits legislated in New York State. The Residency Review Committee for Surgery monitors programs for working conditions and will be enforcing new regulations from the Accreditation Council for Graduate Medical Education. Other sources of resident stress must also be addressed.

Burnout, Professional↗
PubMed2003

Development and evaluation of investigational vena caval filters: the complementary roles of in vitro and in vivo studies.

BACKGROUND: The use of animals in medical research raises both ethical and economic concerns. Validated in vitro models allow extensive device testing prior to in vivo studies which limits the numbers of animals required to reach conclusions regarding efficacy and safety. MATERIALS AND METHODS: In vitro studies were conducted in a vena caval simulator (ECU) to evaluate characteristics of filter performance: ability to capture emboli, resistance to vertical movement from lateral forces, resistance to vertical movement from mass impact, and ability to maintain caval flow. These tests are used to select candidate filters for in vivo studies. In vivo filter studies are conducted in an ovine model with filters placed into the vena cava from a jugular or femoral vein approach. At intervals, the animals are sacrificed and both cava and device are evaluated for thrombogenicity, thrombus resolution, and mechanical integrity. Radiographs, intravascular ultrasound, and histology are used to determine outcome. RESULTS: During the 6-year period from 1993 to 1999, 11 vena caval filter types were evaluated. In each case, it was possible to select a single prototype for in vivo study on the basis of four tests. An investigational device was developed that was comparable to the marketed devices with respect to clot capture (P = 0.001), superior to the Greenfield in resistance to movement (P = 0.001), and superior to the VenaTech and Simon Nitinol relative to volume loading (P = 0.01). Problems with metal fatigue prevented clinical development. CONCLUSION: An integrative system of in vitro and in vivo studies allows efficient evaluation of IVC filters and identifies design characteristics associated with clinical functioning. Evaluation over time is essential to determine safety as well as efficacy.

Animals↗
PubMed2003

Normal D-dimer levels do not exclude thrombotic complications in trauma patients.

BACKGROUND: Deep venous thrombosis (DVT) and pulmonary embolism (PE) are common complications in trauma patients. These diagnoses can be difficult and expensive to make. Recent studies report that a negative D-dimer test excludes thrombotic complications. We questioned the predictive value of a D-dimer test to exclude DVT and PE. METHODS: Adult trauma patients admitted March 1999 to March 2001, with an Injury Severity Score > or =9 and expected length of stay >3 days, were approached for enrollment. Bilateral lower extremity duplex ultrasounds and d-dimer levels were performed within 36 hours of admission, day 3-4, day 7, and weekly until discharge. RESULTS: Twenty-three patients were diagnosed with DVTs, with 18 DVTs detected within the first week of admission. Five DVT patients had normal D-dimer levels. One of three PE patients tested had a normal D-dimer level. The false negative rate for DVT by d-dimer assay was 24%, and the sensitivity was 76%. The negative predictive value for D-dimers was 92%. All false negative d-dimer tests occurred in patients diagnosed with DVT or PE within the 4 days after admission. CONCLUSION: In the early postinjury phase, a negative d-dimer test does not exclude DVT or PE. However, the negative predictive value of a D-dimer test after the first 4 days from admission rose to 100%. Patients with clinical signs and symptoms of DVT or PE in the immediate postinjury phase should undergo further screening to exclude thromboembolic complications.

False Negative Reactions↗
PubMed2003

Factors associated with recurrent venous thromboembolism in patients with malignant disease.

PURPOSE: The role of prophylactic vena cava filters (VCF) in patients with cancer is debated. Although VCF are often placed in patients with cancer after recurrence of venous thromboembolic events (VTE), identification of this subset of patients has not been well-defined. This study was undertaken to assess factors associated with increased risk for recurrent VTE. METHODS: All patients with a history of thromboembolism or malignant disease and who required a VCF because of failure of or contraindication to anticoagulation therapy were abstracted from the Michigan Filter Registry. Univariate analysis of potential risk factors for recurrent VTE and logistic regression models were used to identify associations between these variables and recurrent VTE. RESULTS: Ninety-nine patients (49 men, 50 women) with a mean age of 58 years were included in the study. New metastases occurred in 55% of patients, and 12% of patients had a history of VTE before cancer diagnosis. Corticosteroid agents were used during therapy in 48% of patients. Acute VTE was present in 52% of patients at cancer diagnosis, and in 34% of patients VTE was associated with new metastases. Recurrent VTE occurred in 40% of patients, and significant risk factors included presence of new metastases (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.16-9.09; P =.02) and history of VTE (OR, 10.6; CI, 1.98-57.2; P =.006). Whereas a single episode of neutropenia did not reach significance (OR, 1.1; CI, 0.97-1.35; P =.11), multiple neutropenic episodes were significantly associated with recurrent VTE (P =.04). Smoking, hormone replacement therapy, decreased mobility, post-surgical state, and obesity were not independently associated with increased risk. Mean survival in this series was 30 months, and was significantly worse in patients with VTE at cancer diagnosis and with inability to tolerate anticoagulant therapy in conjunction with VCF. CONCLUSION: Patients with malignant disease may be at increased risk for recurrent VTE after development of new metastases or multiple episodes of neutropenia, especially those patients with a history of VTE. VCF may be a reasonable alternative to long-term anticoagulation therapy in this subgroup of patients at high risk patients, provided their quality of life is reasonable.

Adolescent↗
PubMed2002

Compression stockings and venous function.

HYPOTHESIS: Surgical compression stockings measurably improve venous physiologic mechanisms, and stocking brands do not differ from one another. METHODS: Eleven patients, (8 men and 3 women [mean age, 53 years]), were included. Six patients had primary venous insufficiency and 5 patients had secondary venous insufficiency; 5 patients were in CEAP class 4 and 6 were in CEAP class 5. Patients were randomly assigned to a sequence of 4 brands of knee-high, open-toe, 30- to 40-mm Hg stockings. Each patient wore a stocking for a 1-month equilibration period, then a different stocking monthly for 4 months in a row. Air plethysmography examinations were performed with and without stockings before and after each month of wear. Patients filled out a daily stocking record log and a monthly satisfaction survey. Stockings underwent compression testing after use. RESULTS: Stockings controlled reflux better than they improved calf muscle pump function. With stockings on, patients in CEAP 4 benefited more than those in CEAP 5 in decreasing reflux, while patients in CEAP 5 benefited more than those in CEAP 4 in improving calf muscle pump function. Changes in residual volume fraction were improved in patients in CEAP 5 wearing stockings but not in patients in CEAP 4. Patients with primary disease had greater volumes of reflux and calf ejection than with secondary disease. There were no hemodynamic differences between stocking brands but there were differences in patient compliance and acceptance. CONCLUSIONS: Surgical support stockings seem to be more effective in controlling reflux than in improving calf muscle pump function. All stocking brands function equally as measured by air plethysmography.

Bandages↗