Publications by authors named "Asad Choudhry"

27 Publications

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Contextual and individual factors associated with knowledge, awareness and attitude on liver diseases: A large-scale Asian study.

J Viral Hepat 2021 Nov 24. Epub 2021 Nov 24.

Kantar Health, Singapore, Singapore.

There are limited data to provide better understanding of the knowledge/awareness of general population towards liver health in Asia. We sought to identify the knowledge gaps and attitudes towards liver health and liver diseases as well as evaluate associated individual-level and macro-level factors based on contextual analysis. An online survey assessing knowledge, awareness and attitudes towards liver health and disease was conducted among 7500 respondents across 11 countries/territories in Asia. A liver index was created to measure the respondents' knowledge level and the degree of awareness and attitudes. Multilevel logistic regression was performed to identify individual factors and contextual effects that were associated with liver index. The overall liver index (0-100-point scale) was 62.4 with 6 countries/territories' liver indices greater than this. In the multilevel model, the inclusion of geographical information could explain for 9.6% of the variation. Residing in a country/territory with higher HBV prevalence (80% IOR: 1.20-2.79) or higher HCV death rate (80% IOR: 1.35-3.13) increased the individual probability of obtaining a high overall liver index. Individual factors like age, gender, education, household income, disease history and health screening behaviour were also associated with liver index (all p-values<0.001). The overall liver index was positively associated with the two macro-level factors viz. HBV prevalence and HCV death rate. There is a need to formulate policies especially in regions of lower HBV prevalence and HCV death rate to further improve the knowledge, awareness and attitudes of the general public towards liver diseases.
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http://dx.doi.org/10.1111/jvh.13636DOI Listing
November 2021

Hybrid endovascular exclusion of a bleeding innominate artery pseudoaneurysm in a patient with no open surgical options.

J Vasc Surg Cases Innov Tech 2019 Jun 28;5(2):132-135. Epub 2019 Apr 28.

Division of Vascular Surgery and Endovascular Services, SUNY Upstate University, Syracuse, NY.

Mycotic pseudoaneurysms (MPs) rarely affect the aortic arch vessels and usually require surgical resection for definitive treatment. In this case, a 58-year-old woman developed a bleeding innominate artery MP after primary lung cancer resection complicated by an infected chest wound. Because of her previous surgery, irradiation, and chest wall reconstruction, she was not a candidate for open resection. A hybrid endovascular approach successfully excluded her innominate artery MP through placement of an aortic arch stent graft. Cerebral circulation was maintained through a periscoped left common carotid artery stent graft to the descending thoracic aorta graft, which supplied a left-to-right carotid-carotid bypass.
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http://dx.doi.org/10.1016/j.jvscit.2018.12.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6529683PMC
June 2019

Enhanced readability of discharge summaries decreases provider telephone calls and patient readmissions in the posthospital setting.

Surgery 2019 04 19;165(4):789-794. Epub 2018 Nov 19.

Department of Surgery, Mayo Clinic, Rochester, MN. Electronic address:

Introduction: Hospital discharge instructions provide critical information necessary for patients to manage their own care; however, often they are written at a substantially higher readability level than recommended (ie, 6th-grade level) by the American Medical Association and the National Institutes of Health. We hypothesize that improving the reading level of discharge instructions will decrease the number of patient telephone calls and readmissions in the posthospital setting.

Methods: We conducted a prospective observational study. Patient discharge instructions were edited and incorporated to enhance the readability level in August 2015. Return telephone call and readmissions of patients admitted before the intervention from August 1, 2014, to January 31, 2015, were compared with the prospective cohort studied from September 1, 2015, to September 30, 2016.

Results: A total of 1,072 patients were included (preintervention: n = 493, postintervention: n = 579). Patient demographics, injury characteristics, and education level were similar among both groups. The median discharge instruction readability level in the postintervention group was significantly lower (10.0, 95% CI 10.0-10.2 vs 8.6, 95% CI 8.8-8.9; P < .0001). The proportion of patients calling after hospital discharge was significantly reduced after the intervention (21.9% vs 9.0%; P < .0001). Monthly hospital readmissions were decreased by 50% for every 100 patients discharged after the intervention (1.9% vs 0.9%; P = .002). The proportion of patients calling and readmissions for poor pain control significantly decreased after the intervention (7.1% vs 2.59%; P = .0005 and 2.8% vs 1.0%; P = .029, respectively).

Conclusion: Enhanced readability of discharge instructions was associated with a decrease in the number of telephone calls and readmissions in the posthospital setting, enhancing health literacy and simultaneously reducing the burden on providers. Improved patient instructions written to an appropriate level may also allow for better pain control in the posthospital setting.
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http://dx.doi.org/10.1016/j.surg.2018.10.014DOI Listing
April 2019

Deconstructing dogma: Nonoperative management of small bowel obstruction in the virgin abdomen.

J Trauma Acute Care Surg 2018 07;85(1):33-36

From the Division of Trauma, Critical Care and Emergency Surgery (M.L.C., T.M.D., M.C.-F., B.M.), John Peter Smith Health Network, Fort Worth, Texas; Division of Trauma (N.N.H., M.D.Z., M.D.R.-Z.), Critical Care and General Surgery, Mayo Clinic, Rochester, Minnesota; and Division of Trauma and Surgical Critical Care Services (D.D.Y.), University of Miami Miller School of Medicine, Miami, Florida.

Background: Management of small bowel obstruction (SBO) has become more conservative, especially in those patients with previous abdominal surgery (PAS). However, surgical dogma continues to recommend operative exploration for SBO with no PAS. With the increased use of computed tomography imaging resulting in more SBO diagnoses, it is important to reevaluate the role of mandatory operative exploration. Gastrografin (GG) administration decreases the need for operative exploration and may be an option for SBO without PAS. We hypothesized that the use of GG for SBO without PAS will be equally effective in reducing the operative exploration rate compared with that for SBO with PAS.

Methods: A post hoc analysis of prospectively collected data was conducted for patients with SBO from February 2015 through December 2016. Patients younger than 18 years, pregnant patients, and patients with evidence of hypotension, bowel strangulation, peritonitis, closed loop obstruction or pneumatosis intestinalis were excluded. The primary outcome was operative exploration rate for SBO with or without PAS. Rate adjustment was accomplished through multivariate logistic regression.

Results: Overall, 601 patients with SBO were included in the study, 500 with PAS and 101 patients without PAS. The two groups were similar except for age, sex, prior abdominal surgery including colon surgery, prior SBO admission, and history of cancer. Multivariate analysis showed that PAS (odds ratio [OR], 0.47; p = 0.03) and the use of GG (OR, 0.11; p < 0.01) were independent predictors of successful nonoperative management, whereas intensive care unit admission (OR, 16.0; p < 0.01) was associated with a higher likelihood of need for operation. The use of GG significantly decreased the need for operation in patients with and without PAS.

Conclusions: Patients with and without PAS who received GG had lower rates of operative exploration for SBO compared with those who did not receive GG. Patients with a diagnosis of SBO without PAS should be considered for the nonoperative management approach using GG.

Level Of Evidence: Therapeutic, level IV.
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http://dx.doi.org/10.1097/TA.0000000000001941DOI Listing
July 2018

Breast Cancer Litigation in the 21st Century.

Ann Surg Oncol 2018 Oct 28;25(10):2939-2947. Epub 2018 Jun 28.

Department of Surgery, Mayo Clinic, Rochester, MN, USA.

Background: Approximately 15% of general surgeons practicing in the United States face a medical malpractice lawsuit each year. This study aimed to determine the reasons for litigation for breast cancer care during the past 17 years by reviewing a public legal database.

Methods: The LexisNexis legal database was queried using a comprehensive list of terms related to breast cancer, identifying all cases from 2000 to 2017. Data were abstracted, and descriptive analyses were performed.

Results: The study identified 264 cases of litigation pertaining to breast cancer care. Delay in breast cancer diagnosis was the most common reason for litigation (n = 156, 59.1%), followed by improperly performed procedures (n = 26, 9.8%). The medical specialties most frequently named in lawsuits as primary defendants were radiology (n = 76, 28.8%), general surgery (n = 74, 28%), and primary care (n = 52, 19.7%). The verdict favored the defendant in 145 cases (54.9%) and the plantiff in 60 cases (22.7%). In 59 cases (22.3%), a settlement was reached out of court. The median plaintiff verdict payouts ($1,485,000) were greater than the settlement payouts ($862,500) (p = 0.04).

Conclusion: Failure to diagnose breast cancer in a timely manner was the most common reason for litigation related to breast cancer care in the United States. General surgery was the second most common specialty named in the malpractice cases studied. Most cases were decided in favor of the defendant, but when the plaintiff received a payout, the amount often was substantial. Identifying the most common reasons for litigation may help decrease this rate and improve the patient experience.
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http://dx.doi.org/10.1245/s10434-018-6579-2DOI Listing
October 2018

Prothrombin Complex Concentrate Reversal of Coagulopathy in Emergency General Surgery Patients.

World J Surg 2018 08;42(8):2383-2391

Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic 200 First St SW, Rochester, MN, 55905, USA.

Background: Coagulopathy can delay or complicate surgical diseases that require emergent surgical treatment. Prothrombin complex concentrates (PCC) provide concentrated coagulation factors which may reverse coagulopathy more quickly than plasma (FFP) alone. We aimed to determine the time to operative intervention in coagulopathic emergency general surgery patients receiving either PCC or FFP. We hypothesize that PCC administration more rapidly normalizes coagulopathy and that the time to operation is diminished compared to FFP alone.

Methods: Single institution retrospective review was performed for coagulopathic EGS patients during 2/1/2008 to 8/1/2016. Patients were divided into three groups (1) PCC alone (2) FFP alone and (3) PCC and FFP. The primary outcome was the duration from clinical decision to operate to the time of incision. Summary and univariate analyses were performed.

Results: Coagulopathic EGS patients (n = 183) received the following blood products: PCC (n = 20, 11%), FFP alone (n = 119, 65%) and PCC/FFP (n = 44, 24%). The mean (± SD) patient age was 71 ± 13 years; 60% were male. The median (IQR) Charlson comorbidity index was similar in all three groups (PCC = 5(4-6), FFP = 5(4-7), PCC/FFP = 5(4-6), p = 0.33). The mean (± SD) dose of PCC administered was similar in the PCC/FFP group and the PCC alone group (2539 ± 1454 units vs. 3232 ± 1684, p = .09). The mean (±SD) time to incision in the PCC alone group was significantly lower than the FFP alone group (6.0 ± 3.6 vs. 8.8 ± 5.0 h, p = 0.01). The mean time to incision in the PCC + FFP group was also significantly lower than the FFP alone group (7.1 ± 3.6 vs. 8.8 ± 5.0, p = 0.03). The incidence of thromboembolic complications was similar in all three groups.

Conclusions: PCC, alone or in combination with FFP, reduced INR and time to surgery effectively and safely in coagulopathic EGS patients without an apparent increased risk of thromboembolic events, when compared to FFP use alone.

Level Of Evidence: IV single institutional retrospective review.
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http://dx.doi.org/10.1007/s00268-018-4520-2DOI Listing
August 2018

Validation of AAST EGS Grade for Acute Pancreatitis.

J Gastrointest Surg 2018 03 16;22(3):430-437. Epub 2018 Jan 16.

Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.

Background: The AAST recently developed an emergency general surgery (EGS) disease grading system to measure anatomic severity. We aimed to validate this grading system for acute pancreatitis and compare cross sectional imaging-based AAST EGS grade and compare with several clinical prediction models. We hypothesize that increased AAST EGS grade would be associated with important physiological and clinical outcomes and is comparable to other severity grading methods.

Methods: Single institution retrospective review of adult patients admitted with acute pancreatitis during 10/2014-1/2016 was performed. Patients without imaging were excluded. Imaging, operative, and pathological AAST grades were assigned by two reviewers. Summary and univariate analyses were performed. AUROC analysis was performed comparing AAST EGS grade with other severity scoring systems.

Results: There were 297 patients with a mean (±SD) age of 55 ± 17 years; 60% were male. Gallstone pancreatitis was the most common etiology (28%). The overall complication, mortality, and ICU admission rates were 51, 1.3, and 25%, respectively. The AAST EGS imaging grade was comparable to other severity scoring systems that required multifactorial data for readmission, mortality, and length of stay.

Conclusions: The AAST EGS grade for acute pancreatitis demonstrates initial validity; patients with increasing AAST EGS grade demonstrated longer hospital and ICU stays, and increased rates of readmission. AAST EGS grades assigned using cross sectional imaging findings were comparable to other severity scoring systems. Further studies should determine the generalizability of the AAST system.

Level Of Evidence: IV Study Type: Single institutional retrospective review.
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http://dx.doi.org/10.1007/s11605-017-3662-0DOI Listing
March 2018

The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction.

J Trauma Acute Care Surg 2018 02;84(2):372-378

From the Division of Trauma Critical Care and General Surgery, Department of Surgery (M.C.H., N.N.H., M.D.Z., A.C.), Mayo Clinic, Rochester, Minnesota; Department of Surgery (D.C.C.), Marshfield Clinic, Marshfield, Wisconsin; Division of Trauma, Department of Surgery (D.T., J-M.Y.), Loma Linda University, Loma Linda, California; Division of Trauma Surgery, Department of Surgery (S.W.), Cooper University Hospital, New Jersey; Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery (K.I.), University of Southern California, Los Angeles, California; Department of Surgery (D.D.Y.), Massachusetts General Hospital, Boston, Massachusetts; Division of Trauma Surgery, Department of Surgery (T.M.D.), John Peter Smith, Fort Worth, Texas; Department of Surgery (A.P.), Kern Medical Center, Baekrsfield, California; Division of Trauma, Department of Surgery (J.W.), Inova Fairfax Hospital, Annandale, Virginia; Division of Trauma, Department of Surgery (C.J.R.), Water Reed National Military Medical Center, Bethesda, Maryland; Department of Surgery (K.A.W.), Geisinger Medical Center, Danville, Pennsylvania; Department of Surgery (J.C.), Greenville Memorial Hospital, Greenville, South Carolina; Department of Surgery (J.D.), UC Health Northern Colorado, Fort Collins, Colorado; Department of Surgery (E.A.T.), East Carolina University, Greenville, North Carolina; and Department of Surgery (J.C.G.), San Antonio Military Medical Center, San Antonio, Texas.

Background: The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) was validated at a single institution. We aimed to externally validate the AAST ASBO grading system using the Eastern Association for the Surgery of Trauma multi-institutional small bowel obstruction prospective observational study.

Methods: Adults (age ≥ 18) with (ASBO) were included. Baseline demographics, physiologic parameters (heart rate, blood pressure, respiratory rate), laboratory tests (lactate, hemoglobin, creatinine, leukocytosis), imaging findings, operative details, length of stay, and Clavien-Dindo complications were collected. The AAST ASBO grades were assigned by two independent reviewers based on imaging findings. Kappa statistic, univariate, and multivariable analyses were performed.

Results: There were 635 patients with a mean (±SD) age of 61 ± 17.8 years, 51% female, and mean body mass index was 27.5 ± 8.1. The AAST ASBO grades were: grade I (n = 386, 60.5%), grade II (n = 135, 21.2%), grade III (n = 59, 9.2%), grade IV (n = 55, 8.6%). Initial management included: nonoperative (n = 385; 61%), laparotomy (n = 200, 31.3%), laparoscopy (n = 13, 2.0%), and laparoscopy converted to laparotomy (n = 37, 5.8%). An increased median [IQR] AAST ASBO grade was associated with need for conversion to an open procedure (2 [1-3] vs. 3 [2-4], p = 0.008), small bowel resection (2 [2-2] vs. 3 [2-4], p < 0.0001), postoperative temporary abdominal closure (2 [2-3] vs. 3 [3-4], p < 0.0001), and stoma creation (2 [2-3] vs. 3 [2-4], p < 0.0001). Increasing AAST grade was associated with increased anatomic severity noted on imaging findings, longer duration of stay, need for intensive care, increased rate of complication, and higher Clavien-Dindo complication grade.

Conclusion: The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research focused on optimizing preoperative diagnosis and management algorithms.

Level Of Evidence: Prognostic, level III.
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http://dx.doi.org/10.1097/TA.0000000000001736DOI Listing
February 2018

Perioperative use of nonsteroidal anti-inflammatory drugs and the risk of anastomotic failure in emergency general surgery.

J Trauma Acute Care Surg 2017 10;83(4):657-661

From the Mayo Clinic, Department of Surgery, Division of Trauma, Critical Care and General Surgery (N.N.H., M.C.H., M.D.Z., A.J.C.), Rochester, Minnesota; University of Texas Health Science Center at San Antonio, Department of Surgery (N.N.H.), San Antonio, Texas; University of Maryland School of Medicine, Department of Surgery, Division of Acute Care Surgery (B.R.B., M.H.L., J.J.D.), Baltimore, Maryland; University of Utah, Department of Surgery, Division of General Surgery (T.M.E.), Salt Lake City, Utah; Loma Linda University, Department of Surgery, (D.T.), Loma Linda, California; Johns Hopkins University, Department of Surgery, Division of Acute Care Surgery (J.V.S.), Baltimore, Maryland; Einstein Medical Center, Department of Surgery (A.F.), Philadelphia, Pennsylvania; University of Texas Southwestern/Parkland Hospital, Department of Surgery, (K.A., H.A.P.), Dallas, Texas; East Texas Medical Center (J.S.M.), Alto, Texas; Medical Center of Plano (M.M.C.), Plano, Texas; and Intermountain Medical Center (D.S.M.), Murray, Utah.

Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used analgesic and anti-inflammatory adjuncts. Nonsteroidal anti-inflammatory drug administration may potentially increase the risk of postoperative gastrointestinal anastomotic failure (AF). We aim to determine if perioperative NSAID utilization influences gastrointestinal AF in emergency general surgery (EGS) patients undergoing gastrointestinal resection and anastomosis.

Methods: Post hoc analysis of a multi-institutional prospectively collected database was performed. Anastomotic failure was defined as the occurrence of a dehiscence/leak, fistula, or abscess. Patients using NSAIDs were compared with those without. Summary, univariate, and multivariable analyses were performed.

Results: Five hundred thirty-three patients met inclusion criteria with a mean (±SD) age of 60 ± 17.5 years, 53% men. Forty-six percent (n = 244) of the patients were using perioperative NSAIDs. Gastrointestinal AF rate between NSAID and no NSAID was 13.9% versus 10.7% (p = 0.26). No differences existed between groups with respect to perioperative steroid use (16.8% vs. 13.8%; p = 0.34) or mortality (7.39% vs. 6.92%, p = 0.84). Multivariable analysis demonstrated that perioperative corticosteroid (odds ratio, 2.28; 95% confidence interval, 1.04-4.81) use and the presence of a colocolonic or colorectal anastomoses were independently associated with AF. A subset analysis of the NSAIDs cohort demonstrated an increased AF rate in colocolonic or colorectal anastomosis compared with enteroenteric or enterocolonic anastomoses (30.0% vs. 13.0%; p = 0.03).

Conclusion: Perioperative NSAID utilization appears to be safe in EGS patients undergoing small-bowel resection and anastomosis. Nonsteroidal anti-inflammatory drug administration should be used cautiously in EGS patients with colon or rectal anastomoses. Future randomized trials should validate the effects of perioperative NSAIDs use on AF.

Level Of Evidence: Therapeutic study, level III.
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http://dx.doi.org/10.1097/TA.0000000000001583DOI Listing
October 2017

Medical Malpractice Lawsuits Involving Surgical Residents.

JAMA Surg 2018 01;153(1):8-13

Department of Surgery, Mayo Clinic, Rochester, Minnesota.

Importance: Medical malpractice litigation against surgical residents is rarely discussed owing to assumed legal doctrine of respondeat superior, or "let the master answer."

Objective: To better understand lawsuits targeting surgical trainees to prevent future litigation.

Design, Setting, And Participants: Westlaw, an online legal research database containing legal records from across the United States, was retrospectively reviewed for malpractice cases involving surgical interns, residents, or fellows from January 1, 2005, to January 1, 2015. Infant-related obstetric and ophthalmologic procedures were excluded.

Exposures: Involvement in a medical malpractice case.

Main Outcomes And Measures: Data were collected on patient demographics, case characteristics, and outcomes and were analyzed using descriptive statistics.

Results: During a 10-year period, 87 malpractice cases involving surgical trainees were identified. A total of 50 patients were female (57%), and 79 were 18 years of age or older (91%), with a median patient age of 44.5 years (interquartile range, 45-56 years). A total of 67 cases (77%) resulted in death or permanent disability. Most cases involved elective surgery (61 [70%]) and named a junior resident as a defendant (24 of 35 [69%]). Cases more often questioned the perioperative medical knowledge, decision making errors, and injuries (53 [61%]: preoperative, 19 of 53 [36%]) and postoperative, 34 of 53 [64%]) than intraoperative errors and injuries (43 [49%]). Junior residents were involved primarily with lawsuits related to medical decision making (21 of 24 [87%]). Residents' failure to evaluate the patient was cited in 10 cases (12%) and lack of direct supervision by attending physicians was cited in 48 cases (55%). A total of 42 cases (48%) resulted in a jury verdict or settlement in favor of the plaintiff, with a median payout of $900 000 (range, $1852 to $32 million).

Conclusions And Relevance: This review of malpractice cases involving surgical residents highlights the importance of perioperative management, particularly among junior residents, and the importance of appropriate supervision by attending physicians as targets for education on litigation prevention.
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http://dx.doi.org/10.1001/jamasurg.2017.2979DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5833625PMC
January 2018

Mortality after emergent trauma laparotomy: A multicenter, retrospective study.

J Trauma Acute Care Surg 2017 09;83(3):464-468

From the The University of Texas McGovern Medical School at Houston (J.A.H., J.B.H.), Houston, Texas; The University of Southern California Keck School of Medicine (T.M., K.I.), Los Angeles, California; Harvard Medical School (M.A.M.-A., D.R.K.), Boston, Massachusetts; Mayo Clinic (A.J.C., M.D.Z.), Rochester, Minnesota; Baylor College of Medicine (S.A., S.R.T.), Houston, Texas; The University of Alabama School of Medicine (R.L.G., J.D.K.), Birmingham, Alabama; The Rutgers New Jersey Medical School (J.A.B., D.H.L.), Newark, New Jersey; The University of Maryland School of Medicine (K.C., D.M.S.), Baltimore, Maryland; The University of Washington Harborview Medical Center (L.C., E.M.B.), Seattle, Washington; The West Virginia University School of Medicine (A.W.), Morgantown, West Virginia; Oregon Health & Science University (V.J.U.P., M.A.S.), Portland, Oregon; and The University of Michigan Medical School (J.R.C.-B., H.B.A.), Ann Arbor, Michigan.

Background: Two decades ago, hypotensive trauma patients requiring emergent laparotomy had a 40% mortality. In the interim, multiple interventions to decrease hemorrhage-related mortality have been implemented but few have any documented evidence of change in outcomes for patients requiring emergent laparotomy. The purpose of this study was to determine current mortality rates for patients undergoing emergent trauma laparotomy.

Methods: A retrospective cohort of all adult, emergent trauma laparotomies performed in 2012 to 2013 at 12 Level I trauma centers was reviewed. Emergent trauma laparotomy was defined as emergency department (ED) admission to surgical start time in 90 minutes or less. Hypotension was defined as arrival ED systolic blood pressure (SBP) ≤90 mm Hg. Cause and time to death was also determined. Continuous data are presented as median (interquartile range [IQR]).

Results: One thousand seven hundred six patients underwent emergent trauma laparotomy. The cohort was predominately young (31 years; IQR, 24-45), male (84%), sustained blunt trauma (67%), and with moderate injuries (Injury Severity Score, 19; IQR, 10-33). The time in ED was 24 minutes (IQR, 14-39) and time from ED admission to surgical start was 42 minutes (IQR, 30-61). The most common procedures were enterectomy (23%), hepatorrhaphy (20%), enterorrhaphy (16%), and splenectomy (16%). Damage control laparotomy was used in 38% of all patients and 62% of hypotensive patients. The Injury Severity Score for the entire cohort was 19 (IQR, 10-33) and 29 (IQR, 18-41) for the hypotensive group. Mortality for the entire cohort was 21% with 60% of deaths due to hemorrhage. Mortality in the hypotensive group was 46%, with 65% of deaths due to hemorrhage.

Conclusion: Overall mortality rate of a trauma laparotomy is substantial (21%) with hemorrhage accounting for 60% of the deaths. The mortality rate for hypotensive patients (46%) appears unchanged over the last two decades and is even more concerning, with almost half of patients presenting with an SBP of 90 mm Hg or less dying.
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http://dx.doi.org/10.1097/TA.0000000000001619DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5573610PMC
September 2017

Incompatible type A plasma transfusion in patients requiring massive transfusion protocol: Outcomes of an Eastern Association for the Surgery of Trauma multicenter study.

J Trauma Acute Care Surg 2017 07;83(1):25-29

From the Loma Linda University School of Medicine, Department of Pathology (W.T.S.) and Trauma Division, Department of Surgery (X.L.-O., D.T., Q.J.C.), Loma Linda, California; Emory School of Medicine, Department of Surgery-Grady Memorial Hospital (B.C.M., C.J.D., C.A.F.), Atlanta, Georgia; University of Kentucky (A.B., D.D.), Department of Surgery, Lexington, Kentucky; San Antonio Military Medical Center, Division of Trauma Critical Care (V.G.S.), Department of Pathology (J.G., J.Q.), and Uniformed Services University of the Health Sciences (P.M.C.), San Antonio, Texas; University of Cincinnati (M.G., T.P., D.G.), Cincinnati, Ohio; Department of Trauma Research, Medical City Plano, Plano, Texas; The Medical Center of Plano (R.D.), Plano, Texas; Conemaugh Memorial Medical Center (M.C.), Johnstown, Pennsylvania; Mayo Clinic, Department of Surgery; Division of Trauma, Critical Care and General Surgery; Rochester, Minnesota.

With a relative shortage of type AB plasma, many centers have converted to type A plasma for resuscitation of patients whose blood type is unknown. The goal of this study is to determine outcomes for trauma patients who received incompatible plasma transfusions as part of a massive transfusion protocol (MTP).

Methods: As part of an Eastern Association for the Surgery of Trauma multi-institutional trial, registry and blood bank data were collected from eight trauma centers for trauma patients (age, ≥ 15 years) receiving emergency release plasma transfusions as part of MTPs from January 2012 to August 2016. Incompatible type A plasma was defined as transfusion to patient blood type B or type AB.

Results: Of the 1,536 patients identified, 92% received compatible plasma transfusions and 8% received incompatible type A plasma. Patient characteristics were similar except for greater penetrating injuries (48% vs 36%; p = 0.01) in the incompatible group. In the incompatible group, patients were transfused more plasma units at 4 hours (median, 9 vs. 5; p < 0.001) and overall for stay (11 vs. 9; p = 0.03). No hemolytic transfusion reactions were reported. Two transfusion-related acute lung injury events were reported in the compatible group. Between incompatible and compatible groups, there was no difference in the rates of acute respiratory distress syndrome (6% vs. 8%; p = 0.589), thromboembolic events (9% vs. 7%; p = 0.464), sepsis (6% vs. 8%; p = 0.589), or acute renal failure (8% vs. 8%, p = 0.860). Mortality at 6 (17% vs. 15%, p = 0.775) and 24 hours (25% vs. 23%, p = 0.544) and at 28 days or discharge (38% vs. 35%, p = 0.486) were similar between groups. Multivariate regression demonstrated that Injury Severity Score, older age and more red blood cell transfusion at 4 hours were independently associated with death at 28 days or discharge; Injury Severity Score and more red blood cell transfusion at 4 hours were predictors for morbidity. Incompatible transfusion was not an independent determinant of mortality or morbidity.

Conclusion: Transfusion of type A plasma to patients with blood groups B and AB as part of a MTP does not appear to be associated with significant increases in morbidity or mortality.

Level Of Evidence: Therapeutic study, level IV.
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http://dx.doi.org/10.1097/TA.0000000000001532DOI Listing
July 2017

Allegations of Failure to Obtain Informed Consent in Spinal Surgery Medical Malpractice Claims.

JAMA Surg 2017 06 21;152(6):e170544. Epub 2017 Jun 21.

Mayo Clinic Neuro-Informatics Laboratory, Rochester, Minnesota2Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.

Importance: Predictive factors associated with increased risk of medical malpractice litigation have been identified, including severity of injury, physician sex, and error in diagnosis. However, there is a paucity of literature investigating informed consent in spinal surgery malpractice.

Objective: To investigate the failure to obtain informed consent as an allegation in medical malpractice claims for patients undergoing a spinal procedure.

Design, Setting, And Participants: In this retrospective cohort study, a national medicolegal database was searched for malpractice claim cases related to spinal surgery for all years available (ie, January 1, 1980, through December 31, 2015).

Main Outcomes And Measures: Failure to obtain informed consent and associated medical malpractice case verdict.

Results: A total of 233 patients (117 [50.4%] male and 116 [49.8%] female; 80 with no informed consent allegation and 153 who cited lack of informed consent) who underwent spinal surgery and filed a malpractice claim were studied (mean [SD] age, 47.1 [13.1] years in the total group, 45.8 [12.9] years in the control group, and 47.9 [13.3] years in the informed consent group). Median interval between year of surgery and year of verdict was 5.4 years (interquartile range, 4-7 years). The most common informed consent allegations were failure to explain risks and adverse effects of surgery (52 [30.4%]) and failure to explain alternative treatment options (17 [9.9%]). In bivariate analysis, patients in the control group were more likely to require additional surgery (45 [56.3%] vs 53 [34.6%], P = .002) and have more permanent injuries compared with the informed consent group (46 [57.5%] vs 63 [42.0%], P = .03). On multivariable regression analysis, permanent injuries were more often associated with indemnity payment after a plaintiff verdict (odds ratio [OR], 3.12; 95% CI, 1.46-6.65; P = .003) or a settlement (OR, 6.26; 95% CI, 1.06-36.70; P = .04). Informed consent allegations were significantly associated with less severe (temporary or emotional) injury (OR, 0.52; 95% CI, 0.28-0.97; P = .04). In addition, allegations of informed consent were found to be predictive of a defense verdict vs a plaintiff ruling (OR, 0.41; 95% CI, 0.17-0.98; P = .046) or settlement (OR, 0.01; 95% CI, 0.001-0.15; P < .001).

Conclusions And Relevance: Lack of informed consent is an important cause of medical malpractice litigation. Although associated with a lower rate of indemnity payments, malpractice lawsuits, including informed consent allegations, still present a time, money, and reputation toll for physicians. The findings of this study can therefore help to improve preoperative discussions to protect spinal surgeons from malpractice claims and ensure that patients are better informed.
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http://dx.doi.org/10.1001/jamasurg.2017.0544DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5831424PMC
June 2017

Loop ileostomy versus total colectomy as surgical treatment for Clostridium difficile-associated disease: An Eastern Association for the Surgery of Trauma multicenter trial.

J Trauma Acute Care Surg 2017 07;83(1):36-40

From the Virginia Commonwealth University (P.F., V.P.), Richmond, Virginia; University of California San Francisco (R.C.), San Francisco, California; Mayo Clinic Rochester (M.D.Z., A.J.C.), Rochester, New York; University of Maryland School of Medicine (B.B., A.P.), Baltimore, Maryland; Massachusetts General Hospital (D.D.Y.), Boston, Massachusetts; University of Miami Miller School of Medicine (T.L.Z., J.P.M.), Miami, Florida; George Washington University (B.S.), Washington, DC; Loma Linda University and Medical Center (R.D.C.), San Bernardino, California; Albert Einstein College of Medicine (P.K.), New York, New York; The Johns Hopkins University School of Medicine (L.A.D., E.R.H.), Baltimore, Maryland.

Objectives: The mortality of patients with Clostridium difficile-associated disease (CDAD) requiring surgery continues to be very high. Loop ileostomy (LI) was introduced as an alternative procedure to total colectomy (TC) for CDAD by a single-center study. To date, no reproducible results have been published. The objective of this study was to compare these two procedures in a multicentric approach to help the surgeon decide what procedure is best suited for the patient in need.

Methods: This was a retrospective multicenter study conducted under the sponsorship of the Eastern Association for the Surgery of Trauma. Demographics, medical history, clinical presentation, APACHE score, and outcomes were collected. We used the Research Electronic Data Capture tool to store the data. Mann-Whitney (continuous data) and Fisher exact (categorical data) were used to compare TC with LI. Logistic regression was performed to determine predictors of mortality. A propensity score analysis was done to control for potential confounders and determine adjusted mortality rates by procedure type.

Results: We collected data from 10 centers of patients who presented with CDAD requiring surgery between July 1, 2010 and July 30, 2014. Two patients died during the surgical procedure, leaving 98 individuals in the study. The overall mortality was 32%, and 75% had postoperative complications. Median age was 64.5 years; 59% were male. Concerning preoperative patient conditions, 54% were on pressors, 47% had renal failure, and 36% had respiratory failure. When comparing TC and LI, there was no statistical difference regarding these conditions. Univariate preprocedure predictors of mortality were age, lactate, timing of operation, vasopressor use, and acute renal failure. There was no statistical difference between the APACHE score of patients undergoing either procedure (TC, 22 vs LI, 16). Adjusted mortality (controlled for preprocedure confounders) was significantly lower in the LI group (17.2% vs 39.7%; p = 0.002).

Conclusions: This is the first multicenter study comparing TC with LI for the treatment of CDAD. In this study, LI carried less mortality than TC. In patients without contraindications, LI should be considered for the surgical treatment of CDAD.

Level Of Evidence: Therapeutic study, level III.
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http://dx.doi.org/10.1097/TA.0000000000001498DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5998809PMC
July 2017

Surgical Fires and Operative Burns: Lessons Learned From a 33-Year Review of Medical Litigation.

Am J Surg 2017 Mar 12;213(3):558-564. Epub 2016 Dec 12.

Department of Surgery, Mayo Clinic, Rochester, MN, United States. Electronic address:

Objective: We aimed to understand the setting and litigation outcomes of surgical fires and operative burns.

Methods: Westlaw, an online legal research data-set, was utilized. Data were collected on patient, procedure, and case characteristics.

Results: One hundred thirty-nine cases were identified; 114 (82%) operative burns and 25 (18%) surgical fires. Median plaintiff (patient) age was 46 (IQR:28-59). Most common site of operative burn was the face (26% [n = 36]). Most common source of injury was a high energy device (43% [n = 52]). Death was reported in 2 (1.4%) cases. Plaintiff age <18 vs age 18-50 and mention of a non-surgical physician as a defendant both were shown to be independently associated with an award payout (OR = 4.90 [95% CI, 1.23-25.45]; p = .02) and (OR = 4.50 [95% CI, 1.63-13.63]; p = .003) respectively. Plaintiff award payment (settlement or plaintiff verdict) was reported in 83 (60%) cases; median award payout was $215,000 (IQR: $82,000-$518,000).

Conclusion: High energy devices remain as the most common cause of injury. Understanding and addressing pitfalls in operative care may mitigate errors and potentially lessen future liability.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.amjsurg.2016.12.006DOI Listing
March 2017

Increased anatomic severity predicts outcomes: Validation of the American Association for the Surgery of Trauma's Emergency General Surgery score in appendicitis.

J Trauma Acute Care Surg 2017 01;82(1):73-79

From the Division of Trauma Critical Care and General Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.

Background: Determination and reporting of disease severity in emergency general surgery lacks standardization. Recently, the American Association for the Surgery of Trauma (AAST) proposed an anatomic severity grading system. We aimed to validate this system in patients with appendicitis and determine if cross-sectional imaging correlates with disease severity at operation.

Methods: Patients 18 years or older undergoing treatment for acute appendicitis between 2013 and 2015 were identified. Baseline demographics, procedure types were recorded, and AAST grades were assigned based on intraoperative and radiologic findings. Outcomes including length of stay, 30-day mortality, and complications based on Clavien-Dindo categories and National Surgical Quality Improvement Program variables. Summary statistical univariate, nominal logistic, and standard least squares analyses were performed comparing AAST grade with key outcomes. Bland-Altman analysis compared operative findings with preoperative cross-sectional imaging to compare assigning grades.

Results: Three hundred thirty-four patients with mean (±SD) age of 39.3 years (±16.5) were included (53% men), and all patients had cross-sectional imaging. Two hundred ninety-nine underwent appendectomy, and 85% completed laparoscopic. Thirty-day mortality rate was 0.9%, complication rate was 21%. Increased (median [interquartile range, IQR]) AAST grade was recorded in patients with complications (2 [1-4]) compared with those without (1 [1-1], p = 0.001). For operative management, (median [IQR]) AAST grades were significantly associated with procedure type: laparoscopic (1 [1-1]), open (4 [2-5]), conversion to open (3 [1-4], p = 0.001). Increased (median [IQR]) AAST grades were significantly associated in nonoperative management: patients having a complication had a higher median AAST grade (4 [3-5]) compared with those without (3 [2-3], p = 0.001). Bland-Altman analysis comparing AAST grade and cross-sectional imaging demonstrated no difference (-0.02 ± 0.02; p = 0.2; coefficient of repeatability 0.9).

Conclusions: The AAST grading system is valid in our population. Increased AAST grade is associated with open procedures, complications, and length of stay. The AAST emergency general surgery grade determined by preoperative imaging strongly correlated to operative findings.

Level Of Evidence: Epidemiologic/prognostic study, level III.
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http://dx.doi.org/10.1097/TA.0000000000001274DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5337403PMC
January 2017

Medical Malpractice in Bariatric Surgery: a Review of 140 Medicolegal Claims.

J Gastrointest Surg 2017 01 11;21(1):146-154. Epub 2016 Oct 11.

Department of Surgery, Mayo Clinic, Rochester, MN, USA.

Objective: Given the current rate of obesity in the USA, it has been estimated that close to half of the US adult population could be obese by 2030, resulting in greater demand for bariatric procedures. Our objective was to analyze malpractice litigation related to bariatric surgery.

Methods: We conducted a retrospective review of Westlaw (Thompson Reuters) of all bariatric operations that resulted in the filing of a malpractice claim. Each case was reviewed for pertinent medicolegal information related to the procedure, claim, and trial.

Results: The search criteria yielded 298 case briefs, of which 140 met inclusion criteria. Thirty-two percent (n = 49) of cases involved male plaintiffs (patients). Mean patient age with standard deviation (SD) was 43 (10) years. The most common procedure litigated was the Roux-en-Y gastric bypass (76 %, n = 107). Overall, the most common alleged reason for a malpractice claim was delay in diagnosis or management of a complication in the postoperative period (n = 66, 47 %), the most common of which was an anastomotic leak (45 %, n = 34). Death was reported in 74 (52 %) cases. Fifty-seven cases (47 %) were decided in favor of the plaintiff (patient), with a median award payout of $1,090,000 (interquartile range [IQR] $412,500 to $2,550,000).

Conclusion: Delay in diagnosing or managing complications in the postoperative setting, most commonly an anastomotic leak, accounted for the majority of malpractice claims. Measures taken to identify and address anastomotic leaks and other complications early in the postoperative period could potentially reduce the amount of filed malpractice claims related to bariatric surgery.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s11605-016-3273-1DOI Listing
January 2017

Validation of the anatomic severity score developed by the American Association for the Surgery of Trauma in small bowel obstruction.

J Surg Res 2016 08 10;204(2):428-434. Epub 2016 May 10.

Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota. Electronic address:

Background: The anatomic severity schema for small bowel obstruction (SBO) has been described by the American Association for the Surgery of Trauma (AAST). Although acknowledging the importance of physiological and comorbid parameters, these factors were not included in the developed system. Thus, we sought to validate the AAST-SBO scoring system and evaluate the effect of adding patient's physiology and comorbidity on the prediction for the proposed system.

Methods: Patients aged ≥18 y who were treated for SBO at our institution between 2009 and 2012 were identified. The physiology and comorbidity as well as the AAST anatomic scores were determined, squared, and added to calculate the score that we termed Acute General Emergency Surgical Severity-Small Bowel Obstruction (AGESS-SBO). The area under the receiver operating characteristic (AUROC) curve analyses were performed for the AAST anatomic score and compared with the AGESS-SBO score as a predictor for inhospital mortality, extended hospital stay, and inhospital complications.

Results: A total of 351 patients with mean age of 66 ± 17 years were identified, of whom 145 (41%) underwent operation to treat bowel obstruction. Extended hospital stay (>9 d) occurred in 86 patients (25%), inhospital complications in 73 (21%), and inhospital mortality in eight patients (2%). The median (interquartile range [IQR]) AAST anatomic score was 1 point (IQR: 1-2), physiology score was 0 point (IQR: 0-1), and comorbidity score was 1 point (IQR: 1-3); for overall median AGESS-SBO score of 5 points (IQR: 3-13). The AUROC curve analyses demonstrated that the AGESS-SBO system with measures of presenting physiology, comorbidities in addition to AAST anatomic criteria could be beneficial in predicting key outcomes including inhospital mortality (AUROC curve: 0.80 versus 0.54, P = 0.03).

Conclusions: The AAST anatomic score is a reliable system, which assists care providers to categorize SBO. Adding physiology and comorbidity parameters to the described anatomic criteria can be helpful in predicting the outcomes including mortality. Further studies evaluating its usefulness in research and quality improvement purposes across institutions are still required.
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http://dx.doi.org/10.1016/j.jss.2016.04.076DOI Listing
August 2016

Medical malpractice in the management of small bowel obstruction: A 33-year review of case law.

Surgery 2016 10 16;160(4):1017-1027. Epub 2016 Aug 16.

Department of Surgery, Mayo Clinic, Rochester, MN. Electronic address:

Background: Annually, 15% of practicing general surgeons face a malpractice claim. Small bowel obstruction accounts for 12-16% of all surgical admissions. Our objective was to analyze malpractice related to small bowel obstruction.

Methods: Using the search terms "medical malpractice" and "small bowel obstruction," we searched through all jury verdicts and settlements for Westlaw. Information was collected on case demographics, alleged reasons for malpractice, and case outcomes.

Results: The search criteria yielded 359 initial case briefs; 156 met inclusion criteria. The most common reason for litigation was failure to diagnose and timely manage the small bowel obstruction (69%, n = 107). Overall, 54% (n = 84) of cases were decided in favor of the defendant (physician). Mortality was noted in 61% (n = 96) of cases. Eighty-six percent (42/49) of cases litigated as a result of failing to diagnose and manage the small bowel obstruction in a timely manner, resulting in patient mortality, had a verdict with an award payout for the plaintiff (patient). The median award payout was $1,136,220 (range, $29,575-$12,535,000).

Conclusion: A majority of malpractice cases were decided in favor of the defendants; however, cases with an award payout were costly. Timely intervention may prevent a substantial number of medical malpractice lawsuits in small bowel obstruction, arguing in favor of small bowel obstruction management protocols.
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http://dx.doi.org/10.1016/j.surg.2016.06.031DOI Listing
October 2016

Cervical spinal clearance: A prospective Western Trauma Association Multi-institutional Trial.

J Trauma Acute Care Surg 2016 12;81(6):1122-1130

From the LAC+USC Medical Center (K.I., S.B., D.D.), Los Angeles, California; Trauma and Acute Care Surgery Service (L.D.M., M.J.M.), Legacy Emanuel Medical Center, Portland, Oregon; Oregon Health and Science University (D.M.), Portland, Oregon; Scripps Mercy Hospital (K.A.P.), San Diego, California; Cedars-Sinai Medical Center (G.B.), Los Angeles, California; R Adams Cowley Shock Trauma Center (M.J.B.), University of Maryland School of Medicine, Baltimore, Maryland; Cooper University Hospital (J.P.H.), Camden, New Jersey; University of California (R.C.), San Diego, San Diego, California; Mayo Clinic (A.J.C.), Rochester, Minnesota; University Medical Center at Brackenridge (C.V.R.B.), Austin, Texas; University of Calgary-Foothills Medical Center (C.G.B.), Calgary, Alberta, Canada; University of Michigan (J.R.C-B.), Ann Arbor, Michigan; Denver Health Medical Center (C.C.B.), Denver, Colorado; Banner University Medical Center (B.J.), Tucson, AZ; University of Colorado Health-Medical Center of the Rockies (J.D.), Loveland, Colorado; Parkland Memorial Hospital (C.T.M.), University of Texas Southwestern, Dallas, Texas; Medical Center of Plano (M.M.C.), Plano, Texas; and Wesley Medical Center (G.M.B.), Wichita, Kansas.

Background: For blunt trauma patients who have failed the NEXUS (National Emergency X-Radiography Utilization Study) low-risk criteria, the adequacy of computed tomography (CT) as the definitive imaging modality for clearance remains controversial. The purpose of this study was to prospectively evaluate the accuracy of CT for the detection of clinically significant cervical spine (C-spine) injury.

Methods: This was a prospective multicenter observational study (September 2013 to March 2015) at 18 North American trauma centers. All adult (≥18 years old) blunt trauma patients underwent a structured clinical examination. NEXUS failures underwent a CT of the C-spine with clinical follow-up to discharge. The primary outcome measure was sensitivity and specificity of CT for clinically significant injuries requiring surgical stabilization, halo, or cervical-thoracic orthotic placement using the criterion standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings.

Results: Ten thousand seven hundred sixty-five patients met inclusion criteria, 489 (4.5%) were excluded (previous spinal instrumentation or outside hospital transfer); 10,276 patients (4,660 [45.3%] unevaluable/distracting injuries, 5,040 [49.0%] midline C-spine tenderness, 576 [5.6%] neurologic symptoms) were prospectively enrolled: mean age, 48.1 years (range, 18-110 years); systolic blood pressure 138 (SD, 26) mm Hg; median, Glasgow Coma Scale score, 15 (IQR, 14-15); Injury Severity Score, 9 (IQR, 4-16). Overall, 198 (1.9%) had a clinically significant C-spine injury requiring surgery (153 [1.5%]) or halo (25 [0.2%]) or cervical-thoracic orthotic placement (20 [0.2%]). The sensitivity and specificity for clinically significant injury were 98.5% and 91.0% with a negative predictive value of 99.97%. There were three (0.03%) false-negative CT scans that missed a clinically significant injury, all had a focal neurologic abnormality on their index clinical examination consistent with central cord syndrome, and two of three scans showed severe degenerative disease.

Conclusions: For patients requiring acute imaging for their C-spine after blunt trauma, CT was effective for ruling out clinically significant injury with a sensitivity of 98.5%. For patients with an abnormal neurologic examination as the trigger for imaging, there is a small but clinically significant incidence of a missed injury, and further imaging with magnetic resonance imaging is warranted.

Level Of Evidence: Diagnostic tests, level II.
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http://dx.doi.org/10.1097/TA.0000000000001194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5121083PMC
December 2016

Long-term outcomes of gastrografin in small bowel obstruction.

J Surg Res 2016 May 11;202(1):43-8. Epub 2015 Dec 11.

Division of Trauma, Critical Care, and General Surgery, Mayo Clinic, Rochester, Minnesota. Electronic address:

Background: The gastrografin (GG) challenge is a diagnostic and therapeutic tool used to treat patients with small bowel obstruction (SBO); however, long-term data on SBO recurrence after the GG challenge remain limited. We hypothesized that patients treated with GG would have the same long-term recurrence as those treated before the implementation of the GG challenge protocol.

Methods: Patients ≥18 years who were treated for SBO between July 2009 and December 2012 were identified. We excluded patients with contraindications to the GG challenge (i.e., signs of strangulation), patients having SBO within 6-wk of previous abdominal or pelvic surgery and patients with malignant SBO. All patients had been followed a minimum of 1 y or until death. Kaplan-Meier method and Cox regression models were used to describe the time-dependent outcomes.

Results: A total of 202 patients were identified of whom 114 (56%) received the challenge. Mean patients age was 66 y (range, 19-99 y) with 110 being female (54%). A total of 184 patients (91%) were followed minimum of 1 year or death (18 patients lost to follow-up). Median follow-up of living patients was 3 y (range, 1-5 y). During follow-up, 50 patients (25%) experienced SBO recurrences, and 24 (12%) had exploration for SBO recurrence. The 3-year cumulative rate of SBO recurrence in patients who received the GG was 30% (95% confidence interval [CI], 21%-42%) compared to 27% (95% CI, 18%-38%) for those who did not (P = 0.4). The 3-year cumulative rate of exploration for SBO recurrence in patients who received the GG was 15% (95% CI, 8%-26%) compared to 12 % (95% CI, 6%-22%) for those who did not (P = 0.6).

Conclusions: The GG challenge is a clinically useful tool in treating SBO patients with comparable long-term recurrence rates compared to traditional management of SBO.
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http://dx.doi.org/10.1016/j.jss.2015.11.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5245985PMC
May 2016

Readability of discharge summaries: with what level of information are we dismissing our patients?

Am J Surg 2016 Mar 28;211(3):631-6. Epub 2015 Dec 28.

Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Electronic address:

Background: We assessed the health literacy of trauma discharge summaries and hypothesize that they are written at higher-than-recommended grade levels.

Methods: The Flesch-Kincaid grade level (FKGL) and Flesch reading ease scores (FRES), 2 universally accepted scales for evaluating readability of medical information, were used.

Results: A total of 497 patients were included. The mean patient age was 56 ± 22 years. Average FKGL and FRES were 10 ± 1 and 44 ± 7, including 132 summaries classified as very or fairly difficult to read. A total of 204 (65%) patients had functional reading skills at grade levels below the FKGL of their dismissal note; only 74 patients (24%) had the reading skills to adequately comprehend their dismissal summary. Total 30-day readmissions were 40, 65% of whom were patients with inadequate literacy for dismissal summary comprehension.

Conclusions: Patient discharge notes are written at too advanced of an educational level. To ensure patient comprehension, dismissal notes should be rewritten to a 6th-grade level.
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http://dx.doi.org/10.1016/j.amjsurg.2015.12.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5245984PMC
March 2016

Pylephlebitis: a Review of 95 Cases.

J Gastrointest Surg 2016 Mar 10;20(3):656-61. Epub 2015 Jul 10.

Department of Surgery, Mayo Clinic, Rochester, MN, USA.

Pylephlebitis, or suppurative thrombophlebitis of the portal mesenteric venous system occurring in the setting of abdominal inflammatory processes, is a rare but deadly disease commonly associated with diverticulitis. We review our institutional experience in the management of patients with this condition. A retrospective review of medical records from 2002 to 2012 was performed. Patients with a portal mesenteric vein thrombosis (PMVT) within 30 days of an intra-abdominal inflammatory process were identified and evaluated. Ninety-five patients were included. The mean patient age at presentation was 57 years (range, 24-88). The most common associated processes were pancreatitis (31 %), followed by diverticulitis (19 %). Bacteremia was noted in 34 (44 %) patients. The most common organism cultured was Streptococcus viridans. Antibiotic and anticoagulation therapy was given in 86 (91 %) and 78 (82 %) patients, respectively. Overall, we report an 11 % mortality rate. Albeit rare, pylephlebitis most commonly was manifested in the setting of pancreatitis. Treatment should be individualized to culture results and extent of thrombosis. If diagnosed early and managed appropriately, a favorable outcome is possible.
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http://dx.doi.org/10.1007/s11605-015-2875-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4882085PMC
March 2016

Litigation in laparoscopic cholecystectomies.

Am Surg 2014 Jun;80(6):E179-81

Department of Surgery, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA.

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June 2014

Uncovering malpractice in appendectomies: a review of 234 cases.

J Gastrointest Surg 2013 Oct 1;17(10):1796-803. Epub 2013 Aug 1.

Department of Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ, USA.

Background: General surgery is a "high-risk specialty" with respect to medical malpractice rates, and appendicitis is one of the most common diagnoses encountered by practitioners. Our objectives were to detail issues affecting malpractice litigation regarding appendicitis and appendectomies, including outcomes, awards, alleged causes of malpractice, and other factors instrumental in determining legal responsibility and increasing patient safety.

Study Design: Publically available federal and state court records were examined for pertinent jury verdict and settlement reports. Information from 234 pertinent cases was collected, including alleged causes of malpractice and outcomes.

Results: Of the 234 cases included in this study, the most common factor noted was an alleged delay in diagnosis (67.1%), followed by intraoperative negligence (16.2%). Alleged deficits in informed consent, although only specifically cited as a cause of malpractice in 1.3% of cases, were found to be an important aspect of many cases. In total, 59.8% of cases were ruled in favor of the physician, 23.7% in favor of the plaintiff, and 5.5% reached a settlement. The average plaintiff award was US $794,152, and the average settlement award was US $1,434,286.

Conclusion: An important strategy to decrease liability in a physician's practice is prompt evaluation of an appendicitis patient. An integral part of this is efficient communication between physicians practicing a wide variety of specialties, especially including practitioners in emergency medicine and general surgery. Additionally, completing a thorough informed consent explaining all aspects of the procedure including the factors we outline will not only increase patient awareness of potential risks but also protect the physician in the face of litigation.
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http://dx.doi.org/10.1007/s11605-013-2248-8DOI Listing
October 2013

Giant suprasellar Rathke's cleft cyst mimicking craniopharyngioma: implications for a spectrum of cystic epithelial lesions of ectodermal origin.

J Neurol Surg A Cent Eur Neurosurg 2012 Sep 30;73(5):324-9. Epub 2012 Jul 30.

Department of Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, NJ 07101, USA.

Cystic epithelial lesions such as Rathke's cleft cysts (RCCs) and craniopharyngiomas may be difficult to distinguish on a clinical, radiographic, and sometimes histopathological basis. We describe a case of a giant 6.5 cm suprasellar cystic lesion that was presumed to be a craniopharyngioma based on the neuroimaging findings. The lesion extended from the anterior skull base and sella turcica to the lateral ventricle and sylvian fissure resulting in obstructive hydrocephalus. Complete surgical removal of the suprasellar lesion was achieved using an extended frontotemporal transbasal skull base approach. Intraoperatively, the cyst wall was thickened and partially calcified, resembling a craniopharyngioma. However, the histopathological examination revealed findings most consistent with a RCC with additional features of extensive squamous metaplasia, metaplastic bone formation, and chronic inflammation. The case raises the issue of whether there is a pathologic continuum of parasellar ectodermal lesions which may account for the overlap of features and transitional states. In this report, we discuss the possible spectrum between RCCs and craniopharyngiomas, and also emphasize the importance of complete resection of the cyst wall in RCCs that exhibit squamous metaplasia, inflammation, or ossification to minimize the probability of recurrence.
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http://dx.doi.org/10.1055/s-0032-1304814DOI Listing
September 2012

Pituitary tumor apoplexy in patients with Cushing's disease: endocrinologic and visual outcomes after transsphenoidal surgery.

Pituitary 2012 Sep;15(3):428-35

Department of Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, 90 Bergen St, Suite 8100, Newark, NJ 07101, USA.

Pituitary apoplexy in patients with adrenocorticotropic hormone (ACTH) producing tumors is a rare occurrence. We report four patients with Cushing's disease harboring ACTH-secreting macroadenomas who presented with pituitary apoplexy. We report the endocrinologic and visual outcomes of these patients after emergent transsphenoidal surgery. A retrospective chart review was performed in 4 patients who presented with pituitary apoplexy from hemorrhage into an ACTH-secreting pituitary adenoma. The patient charts were reviewed for clinical presentation, neuroimaging findings, intraoperative surgical findings, pathologic findings, and postoperative endocrinologic and visual outcomes. All patients presented with acute headaches, nausea, vomiting, and visual loss from optic compression. MR imaging demonstrated a hemorrhagic macroadenoma that was confirmed at surgery. All patients underwent emergent transsphenoidal decompression (within 24 h of presentation). One of these underwent an additional craniotomy to resect residual tumor. Postoperatively, all patients showed significant improvement in visual acuity and visual fields with biochemical remission confirmed on laboratory testing. Significant weight loss as well as resolution of diabetes and hypertension was noted in all cases. All four patients remained in biochemical remission at their most recent follow-up visit (mean 40 months, range: 24-72 months). Excellent endocrine and visual outcomes can be achieved after emergent transsphenoidal surgery in patients with Cushing's disease presenting with pituitary apoplexy. Although the cure rates of non-apoplectic ACTH macroadenomas are generally poor, higher rates of remission can be achieved in cases of pituitary apoplexy. This may be partly due to the effects of tumor infarction.
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http://dx.doi.org/10.1007/s11102-011-0342-zDOI Listing
September 2012
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