Faculty Bibliography

Understanding how medical malpractice occurs and is resolved is important to improving patient safety and preserving the viability of a physician's career in academic medicine. Every physician is likely to be sued by a patient, and how the physician responds can change his or her professional life. However, the principles of medical malpractice are rarely taught or addressed during residency training. In fact, many faculty at academic medical centers know little about malpractice.In this article, the authors propose that information about the inciting causes of malpractice claims and their resolution should be incorporated into residency professionalism curricula both to improve patient safety and to decrease physician anxiety about a crucial aspect of medicine that is not well understood. The authors provide information on national trends in malpractice litigation and residents' understanding of malpractice, then share the results of their in-depth review of surgical malpractice claims filed during 2001-2008 against their academic medical center. The authors incorporated those data into an evidence-driven curriculum for residents, which they propose as a model for helping residents better understand the events that lead to malpractice litigation, as well as its process and prevention

AIM: To determine whether the location of the computed tomography (CT) whirl sign can be used to help differentiate caecal from sigmoid volvulus. MATERIALS AND METHODS: Thirty-one patients (mean age 64.6 years) underwent multidetector CT and had confirmed colonic volvulus. There were 15 patients with caecal volvulus and 16 with sigmoid volvulus. Axial and coronal images were retrospectively evaluated on the picture archiving and communication system (PACS) by two reviewers in consensus without knowledge of the final diagnosis to determine whether a CT whirl sign was present and, if so, was the location to the right of midline or in the midline/left. The location of the twisting at imaging was correlated with whether the patient had caecal or sigmoid volvulus. Fisher's exact test was used to determine whether there was an association between the location of the twist (right versus mid-left) and the location of the colonic volvulus (caecal versus sigmoid). The non contrast CT (NCCT) examinations of 30 additional patients without colonic volvulus were evaluated for the presence or absence of a CT whirl sign. RESULTS: All 31 patients with colonic volvulus had a CT whirl sign. No patient who underwent NCCT for kidney stones demonstrated a CT whirl sign. According to Fisher's exact test, there was a highly significant association (p<0.0001) between the location of the twist (right versus mid-left) and the location of the colonic volvulus (caecal versus sigmoid). Using the location of the twist as a predictor of whether the volvulus was caecal or sigmoid provided a correct diagnosis for 93.3% (14/15) of the patients with caecal volvulus and 100% (16/16) of those with sigmoid volvulus, yielding an overall diagnostic accuracy of 96.8% (30/31). CONCLUSION: The location of the mesenteric twist (CT whirl sign) is a highly accurate finding in discriminating caecal from sigmoid volvulus

BACKGROUND: The impact of vascular injuries on patient mortality has not been well evaluated in multi-trauma patients. This study seeks to determine (1) whether the presence of vascular trauma negatively affects outcome compared with nonvascular trauma (NVT) and (2) the utility of existing severity scoring systems in predicting mortality among vascular trauma (VT) patients. METHODS: A retrospective review of our trauma database from January 2005 to December 2007 was conducted. Demographics, Injury Severity Scores (ISS), Revised Trauma Scores (RTS), Trauma Score-Injury Severity Scores (TRISS), Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and mortality rates were compared. Control patients were selected from a matching cohort based on ISS. Comparisons were made between groups based on the above scoring systems. Statistical analysis used chi(2) analysis and Student t-tests. RESULTS: Fifty VT and 50 NVT patients were identified with no significant differences in age, gender, mechanism of injury, ISS, RTS, or TRISS. The mean APACHE II score was higher in VT compared with NVT (12.3 vs 8.8, P < .05). Overall mortality was higher in VT compared with NVT but did not reach statistical significance (24% vs 11.8%, P = .108). VT patients with RTS score >5 had a higher mortality rate (26% vs 2.2%, P = .007). VT patients with an ISS score >24 had a higher mortality compared with NVT patients (61% vs 28.6%, P = .04). VT patients with an APACHE II score <14 also had a higher mortality rate (18.2% vs 0%, P = .007). Finally, VT patients with a TRISS probability of survival of >80% had a higher mortality rate (13.9% vs 0%, P = .05). CONCLUSIONS: In multi-trauma patients, the presence of vascular injury was associated with increased mortality in less severely injured patients based on the RTS, TRISS, and APACHE II scores. These scoring systems underestimated mortality in patients with vascular trauma. Level of care and future trauma algorithms should be adjusted in the presence of vascular trauma

Introduction: Surgery offers the only chance for cure in patients with pancreatic cancer. Currently, pancreaticoduodenectomy can be performed with a mortality of under 5% and a morbidity of 40-50%. Little, however, is known about outcomes of pancreaticoduodenectomy (PD) in octogenarians. This manuscript details outcomes after PD for adenocarcinoma in patients 80 years and older. Methods: From our comprehensive pancreatic adenocarcinoma database of 248 patients, we identified 200 patients who underwent PD (1990-2009). We categorized patients into two groups, according to age at time of surgery: Group I (>= 80 year-old) and Group II (< 80 year-old). The study end-points were length of post-operative stay (LOS), overall morbidity, 30-day mortality, overall survival (OS). Differences between groups were evaluated using t-test or chi-squared test. Survival was compared using Kaplan-Meier analysis and log-rank test. Results: There were 25 patients in group I (mean age 83.1) and 175 patients in Group II (mean age 64.4). Octogenarians had worse ECOG performance status (PS >= 1 in 90% vs. 50.8%, p < 0.01) and ASA score (ASA 3- 4 in 70.8% vs. 47.4%, p < 0.01). The two groups were similar in regard to underlying co-morbidities (including coronary artery disease, COPD, diabetes, chronic renal failure), operative time, rates of portal vein resection, intraoperative complications, blood loss, pathologic AJCC stage, status of resection margins. Octogenarians had longer LOS (20 vs. 13.7 days, p=0.01) and higher overall morbidity (68% vs. 44%, p=0.03). There was a single death in each group (p=0.23). At median follow-up of 13 months older patients had a median OS of 17.3 months compared to 13.1 months in younger patients (p=0.06). Conclusions: Surgical morbidity and LOS are significantly increased in octogenarians. However 30-day mortality was not significantly increased and OS was superior (but not statistically significant) when compared to younger patients. The decision for PD should be individualized and offered to carefully selected octogenarians

Background: The AJCC staging for pancreatic cancer is relatively non-discriminatory for prediction of survival after resection. At the Moffitt Cancer Center a prognostic score for patients with localized pancreatic cancer (AJCC <= IIb) has been developed. In the Moffitt Prognostic Index (MPI) patients are grouped in 5 risk categories on the basis of extra-pancreatic tumor extension, degree of differentiation and lymphatic invasion. The aim of this study is to assess the MPI's predictive value in an independent cohort of patients who underwent pancreaticoduodenectomy (PD) at the New York University. Methods From our retrospective pancreatic adenocarcinoma database of 248 patients, we identified and grouped by MPI category patients with AJCC stage <= IIb who underwent PD (1990-2009). Differences between groups were evaluated using ANOVA and chi-squared test. Overall survival (OS) for each group was estimated using the Kaplan-Meier method and compared using the log-rank statistic. Results Among 131 patients with stage Ia-IIb cancer, MPI could be calculated for 126 (96%). Only few patients fell in MPI lower-risk groups 1- 4 (respectively 1, 4, 3, 22), while the majority (96, 76.1%) fell in MPI group 5 (poor prognosis). The 5 groups were similar in demographics, underlying comorbidities, laboratory data, ASA score and ECOG performance status. There were no differences in operative time, blood loss, intra- and post-operative complications, length of stay, 30-day mortality. Pathology revealed more advanced stage in groups 3 to 5 (p=0.001). At mean follow-up of 18 months, there was no difference in median OS across MPI groups (respectively 19, 6, 16, 17, 12 months, p=0.91). Of note, AJCC staging did correlate with median OS (respectively 43, 12, 16, 11 months in stages Ia to IIb, p = 0.004). Conclusions In our experience the MPI performed worse than AJCC staging as a prognostic tool. The clustering of patients in the worst-prognosis group defied the very purpose of prognosis discrimination. Furthermore, in our experience MPI did not correlate with overall survival in patients undergoing DP for earlystage (<= IIb) pancreatic cancer

The normal liver is characterized by immunologic tolerance. Primary mediators of hepatic immune tolerance are liver sinusoidal endothelial cells (LSECs). LSECs block adaptive immunogenic responses to Ag and induce the generation of T regulatory cells. Hepatic fibrosis is characterized by both intense intrahepatic inflammation and altered hepatic immunity. We postulated that, in liver fibrosis, a reversal of LSEC function from tolerogenic to proinflammatory and immunogenic may contribute to both the heightened inflammatory milieu and altered intrahepatic immunity. We found that, after fibrotic liver injury from hepatotoxins, LSECs become highly proinflammatory and secrete an array of cytokines and chemokines. In addition, LSECs gain enhanced capacity to capture Ag and induce T cell proliferation. Similarly, unlike LSECs in normal livers, in fibrosis, LSECs do not veto dendritic cell priming of T cells. Furthermore, whereas in normal livers, LSECs are active in the generation of T regulatory cells, in hepatic fibrosis LSECs induce an immunogenic T cell phenotype capable of enhancing endogenous CTLs and generating potent de novo CTL responses. Moreover, depletion of LSECs from fibrotic liver cultures mitigates the proinflammatory milieu characteristic of hepatic fibrosis. Our findings offer a critical understanding of the role of LSECs in modulating intrahepatic immunity and inflammation in fibro-inflammatory liver disease

BACKGROUND: There is an intuitive belief that in-house trauma attendings benefit patient outcome, although multiple studies have failed to prove this. However, no studies investigate the financial advantage for hospitals by having the attendings also perform urgent general surgery cases (GSC) during nights and weekends. The purpose of this study is to identify how an in-house attending program was used for urgent GSC and to see if it provided a financial benefit to the hospital. METHODS: The in-house program began in October 2007. A retrospective study reviewed all cholecystectomies performed from October 2006 to September 2007 and October 2007 to September 2008. Total length of stay (LOS) was calculated. Total LOS for each group was multiplied by the daily cost for a medical-surgical bed ($2,530.00). The cost difference was calculated for the pre- and post-in-house groups. RESULTS: Two hundred sixty-four cholecystectomies were performed before instituting an in-house attending program compared with 291 cases in the period after a 9% increase. Total LOS for cholecystectomies performed before the program was 6.4 days translating to $16,192.00 in room costs versus 5.24 days after and $13,257.20 in room costs. This translated to a savings of $2,934.80 per patient and $854,026.80 savings in total because of reduced LOS, which subsidized the cost of the program, which was $750,000.00. CONCLUSION: In-house attendings are beneficial in decreasing overall LOS for urgent GSC. This study demonstrates that in-house attendings can perform urgent GSCs and realize a savings for a hospital that can be used to fully subsidize the cost of the program

The liver is the most common site of adenocarcinoma metastases, even in patients who initially present with early disease. We postulated that immune-suppressive cells in the liver of tumor-bearing hosts inhibit anti-tumor T cells, thereby accelerating the growth of liver metastases. Using models of early preinvasive pancreatic neoplasia and advanced colorectal cancer, aims of this study were to determine immune phenotype, stimulus for recruitment, inhibitory effects, and tumor-enabling function of immune-suppressive cells in the liver of tumor-bearing hosts. We found that in mice with intra-abdominal malignancies, two distinct CD11b(+)Gr1(+) populations with divergent phenotypic and functional properties accumulate in the liver, becoming the dominant hepatic leukocytes. Their expansion is contingent on tumor expression of KC. These cells are distinct from CD11b(+)Gr1(+) populations in other tissues of tumor-bearing hosts in terms of cellular phenotype and cytokine and chemokine profile. Liver CD11b(+)Gr1(+) cells are highly suppressive of T cell activation, proliferation, and cytotoxicity and induce the development of Tregs. Moreover, liver myeloid-derived suppressor cells accelerate the development of hepatic metastases by inactivation of cytotoxic T cells. These findings may explain the propensity of patients with intra-abdominal cancers to develop liver metastases and suggest a promising target for experimental therapeutics

Purpose: To determine the frequency of intraductal papillary mucinous neoplasm (IPMN) in patients with and without invasive ductal adenocarcinoma (IDAC). Methods: 82 patients underwent pancreatectomy for pancreas adenocarcinoma. 68/82 subjects underwent at least one preoperative imaging study including CT (n = 43), MRI (n = 25), or both (n = 12). Imaging studies were retrospectively evaluated to determine if IPMN was present in the gland at a location distant from IDAC. In 183 different adult patients undergoing MRI for renal mass, images were evaluated to determine the frequency of IPMN. Fisher's exact test was used to test whether the prevalence of IPMN was greater among patients with pancreas cancer than those without. Results: Five of 68 (7.3%) patients who underwent pancreatic resection for IDAC had IPMN at a site distant from the cancer. Two of 182 (1.1%) patients undergoing MRI for renal cancer had imaging evidence of IPMN. There was a significant difference (p = 0.017) in the prevalence of IPMN between patients with and without IDAC. The odds ratio for IPMN as a predictor of pancreas cancer was estimated as 7.18. Conclusion: IPMN occurs with increased frequency in patients with pancreas cancer as opposed to those without pancreas cancer. and IAP