Cancer patients undergoing radiation therapy need to have baseline studies of cardiac function and routine screening for heart disease, according to recommendations from the European Society of Cardiology and the American Society of Echocardiography published July 16 in the European Heart Journal–Cardiovascular Imaging.

The groups recommend baseline preradiation echocardiography along with a cardiac exam as well as screening for risk factors. An annual cardiac history and physical should be performed to check for new-onset heart problems.

Within 10 years of treatment, 10%-30% of patients who undergo radiation therapy develop radiation-induced heart diseases (RIHD), including chronic pericarditis, myocardial fibrosis, coronary artery disease, aortic calcification, and valve regurgitation or stenosis. The hope of screening is to catch early RIHD, but screening is not currently routine.

"We wrote the expert consensus to raise the alarm that the risks of radiation-induced heart disease should not be ignored. The prevalence ... is increasing because the rate of cancer survival has improved," said Dr. Patrizio Lancellotti, who is a professor of cardiology at the University Hospital of Liège, Belgium, and led the recommendations task force.

Radiotherapy is given in more targeted form and at lower doses than it once was, but "patients are still at increased risk of RIHD, particularly when the heart is in the radiation field. This applies to patients treated for lymphoma, breast cancer, and esophageal cancer. Patients who receive radiotherapy for neck cancer are also at risk because lesions can develop on the carotid artery and increase the risk of stroke," Dr. Lancellotti said in a statement.

Using targeted radiation and alternate radiation fields, with avoidance and shielding of the heart, remain "the most important interventions to prevent" cardiac complications, the authors noted.

The task force advises that high-risk patients without evidence of heart disease on history and physical should have screening echocardiography every 5 years and noninvasive stress testing every 5-10 years; low-risk patients should have screening echocardiography every 10 years. If heart disorders are detected, routine monitoring should include echocardiography, cardiac magnetic resonance imaging, or carotid ultrasound as appropriate.

High-risk patients include those who received radiotherapy at younger ages; those who have cardiovascular risk factors or preexisting heart disease; and those who receive high-dose radiation (greater than 30 Gy), concomitant chemotherapy, radiation without shielding, or anterior or left chest radiation (Eur. Heart J. Cardiovasc. Imaging 2013;14:721-40).

The recommendations are based on an extensive literature review and analysis by Dr. Lancellotti and other specialists.

The authors reported no financial conflicts or outside funding for their work.

[email protected]

Cancer patients undergoing radiation therapy need to have baseline studies of cardiac function and routine screening for heart disease, according to recommendations from the European Society of Cardiology and the American Society of Echocardiography published July 16 in the European Heart Journal–Cardiovascular Imaging.

The groups recommend baseline preradiation echocardiography along with a cardiac exam as well as screening for risk factors. An annual cardiac history and physical should be performed to check for new-onset heart problems.

Within 10 years of treatment, 10%-30% of patients who undergo radiation therapy develop radiation-induced heart diseases (RIHD), including chronic pericarditis, myocardial fibrosis, coronary artery disease, aortic calcification, and valve regurgitation or stenosis. The hope of screening is to catch early RIHD, but screening is not currently routine.

"We wrote the expert consensus to raise the alarm that the risks of radiation-induced heart disease should not be ignored. The prevalence ... is increasing because the rate of cancer survival has improved," said Dr. Patrizio Lancellotti, who is a professor of cardiology at the University Hospital of Liège, Belgium, and led the recommendations task force.

Radiotherapy is given in more targeted form and at lower doses than it once was, but "patients are still at increased risk of RIHD, particularly when the heart is in the radiation field. This applies to patients treated for lymphoma, breast cancer, and esophageal cancer. Patients who receive radiotherapy for neck cancer are also at risk because lesions can develop on the carotid artery and increase the risk of stroke," Dr. Lancellotti said in a statement.

Using targeted radiation and alternate radiation fields, with avoidance and shielding of the heart, remain "the most important interventions to prevent" cardiac complications, the authors noted.

The task force advises that high-risk patients without evidence of heart disease on history and physical should have screening echocardiography every 5 years and noninvasive stress testing every 5-10 years; low-risk patients should have screening echocardiography every 10 years. If heart disorders are detected, routine monitoring should include echocardiography, cardiac magnetic resonance imaging, or carotid ultrasound as appropriate.

High-risk patients include those who received radiotherapy at younger ages; those who have cardiovascular risk factors or preexisting heart disease; and those who receive high-dose radiation (greater than 30 Gy), concomitant chemotherapy, radiation without shielding, or anterior or left chest radiation (Eur. Heart J. Cardiovasc. Imaging 2013;14:721-40).

The recommendations are based on an extensive literature review and analysis by Dr. Lancellotti and other specialists.

The authors reported no financial conflicts or outside funding for their work.

[email protected]

Cancer patients undergoing radiation therapy need to have baseline studies of cardiac function and routine screening for heart disease, according to recommendations from the European Society of Cardiology and the American Society of Echocardiography published July 16 in the European Heart Journal–Cardiovascular Imaging.

The groups recommend baseline preradiation echocardiography along with a cardiac exam as well as screening for risk factors. An annual cardiac history and physical should be performed to check for new-onset heart problems.

Within 10 years of treatment, 10%-30% of patients who undergo radiation therapy develop radiation-induced heart diseases (RIHD), including chronic pericarditis, myocardial fibrosis, coronary artery disease, aortic calcification, and valve regurgitation or stenosis. The hope of screening is to catch early RIHD, but screening is not currently routine.

"We wrote the expert consensus to raise the alarm that the risks of radiation-induced heart disease should not be ignored. The prevalence ... is increasing because the rate of cancer survival has improved," said Dr. Patrizio Lancellotti, who is a professor of cardiology at the University Hospital of Liège, Belgium, and led the recommendations task force.

Radiotherapy is given in more targeted form and at lower doses than it once was, but "patients are still at increased risk of RIHD, particularly when the heart is in the radiation field. This applies to patients treated for lymphoma, breast cancer, and esophageal cancer. Patients who receive radiotherapy for neck cancer are also at risk because lesions can develop on the carotid artery and increase the risk of stroke," Dr. Lancellotti said in a statement.

Using targeted radiation and alternate radiation fields, with avoidance and shielding of the heart, remain "the most important interventions to prevent" cardiac complications, the authors noted.

The task force advises that high-risk patients without evidence of heart disease on history and physical should have screening echocardiography every 5 years and noninvasive stress testing every 5-10 years; low-risk patients should have screening echocardiography every 10 years. If heart disorders are detected, routine monitoring should include echocardiography, cardiac magnetic resonance imaging, or carotid ultrasound as appropriate.

High-risk patients include those who received radiotherapy at younger ages; those who have cardiovascular risk factors or preexisting heart disease; and those who receive high-dose radiation (greater than 30 Gy), concomitant chemotherapy, radiation without shielding, or anterior or left chest radiation (Eur. Heart J. Cardiovasc. Imaging 2013;14:721-40).

The recommendations are based on an extensive literature review and analysis by Dr. Lancellotti and other specialists.

The authors reported no financial conflicts or outside funding for their work.

[email protected]

In the United States, family psychiatrists continue to deal with the fallout from the 1950s and 1960s, when the early family therapists located mental illness within the family and then touted family therapy as the cure. Families felt blamed and shied away from "family therapy."

Yet, research shows that family treatment for many psychiatric and medical illnesses, whether it is family inclusion or psychoeducation, is very effective in reducing morbidity. Stigma and fear about family involvement have resulted in family treatment lagging behind other psychotherapies in its acceptance as a valid therapeutic intervention.

As a contrast, it is therefore interesting to look at Romania, a postcommunist country, where all psychotherapies were deemed "unnecessary" under communism. According to Dr. Ileana-Mihaela Botezat-Antonescu, "Psychotherapy and psychoanalysis were known as the studies of the soul during the communist regime and went underground. Secret psychotherapy meetings were held in Sibiu and Timisoara, but after the 1989 revolution, we had access to information from abroad," she said during a presentation this year at the World Psychiatric Association meeting in Bucharest, Romania.

"In 1990, freedom occurs, but nobody tells you what to do. You cannot count on anything. It alienated people seeking help. It was a process that took time," said Dr. Botezat-Antonescu, a psychiatrist and psychoanalyst who was trained in the mid-1990s by trainers from the Dutch Psychoanalytic Association and serves as chair of the National Center for Mental Health.

Psychotherapists in Romania must somehow address the traumatic environment that lasted a generation. Young people strive to gain their sense of identity and belonging and, at the same time, are challenged with reestablishing a connection between the generations. The sense of intergenerational trauma and loss extends back to grandparents who lost their farms, houses, and social position.

An understanding of the intergenerational transmission of trauma can inform psychotherapists across the globe in their care of young people. Family therapy is a type of psychotherapy that is well suited to address this intergenerational trauma.

Psychological trauma is passed down through the generations in subtle and unspoken ways. It is important for therapists to recognize when this is occurring and work with the whole family. Family therapy that specifically addresses the intergenerational transmission of trauma can help move a family from feelings of helplessness toward resilience.

Development of family therapy

Family therapy developed in Romania through training courses in Cluj, Târgu Mures, and Timisoara. As there were no Romanian trainers, these courses were taught by family therapists from countries such as Ireland, France, and Yugoslavia. Families and trainees spoke Romanian or Hungarian, and during live supervision, simultaneous translation occurred. All courses, readings, and assignments were in English. Family therapy developed in Romania through training courses in Cluj, Târgu Mures and Timisoara.

Trainees saw families in their own work contexts, for example, psychotherapy centers; psychiatry hospitals; and community centers, such as family planning clinics and domestic violence shelters. Currently, there are 16 family therapy professional organizations (Contemp. Fam. Ther. 2013;35:275-87), including:

• Systemic Family Therapy Association in Cluj

• Association of Family Therapy in Bucharest

• Romanian Association for Family and Systemic Therapy in Timisoara

• Association Crisdu Areopagus in Timisoara

• Pro Familia – Family Therapy Association in Miercurea-Ciuc

• Association for Couple and Family Psychotherapy in Iasi

• Association for Family Counselling and Therapy in Iasi

Dr. Zoltán Kónya and Dr. Ágnes Kónya run the family therapy center in Cluj and have written about the challenges of practicing family therapy in Romania (Context 2007;92:2-4 and Contemporary Family Therapy 2013;35:1). Since family therapy training courses developed at different times, in different places, with trainers invited from different countries, the sense of what constitutes family therapy varies across Romania.

The meaning of the word "systemic" has proved particularly contentious. For some, systemic is synonymous with the Milan approach – which is based on the notion that "families are self-regulating systems that function based on self-developed rules tested over time through a process of trial and error" (Case Conceptualization in Family Therapy, Boston: Pearson, 2013). However, others consider family therapy as more than a systemic approach. Some promote systemic thinking as an all-encompassing epistemological frame for consultation with individuals, families, and organizations, but others do not attach much importance to the term "systemic."

The challenge of organizing into one Romanian family therapy institution with one outlook is great. This challenge also replicates one of the major problems in our field – the idea that family therapy means different things to different people. In Romania, well-meaning outside attempts ended up in a fractured national family therapy identity.

The Kónyas, trained by Irish family therapists, identify additional challenges of introducing family therapy into a culture unfamiliar with the concept. "The fit between systemic therapy and Romanian culture has been a concern of ours since the beginning of our training," they wrote in 2003. "There had been no tradition of people seeing psychotherapists in times of distress. Also, the vast majority of health care professionals had not even heard about family therapy. Would families come to therapy?"

They found that not only did clients come to therapy, but they also were ready to work hard when they did.

"We admire our clients’ courage in facing a series of challenges involved in the therapy process: consulting an outsider for a family problem, participating in sessions as a family, being asked unusual questions, being videotaped and, sometimes, being observed by a team and/or supervisors from abroad," they said.

In their work with patients, the Kónyas write, they have encountered difficulties tied to the use of words and phrases used in systemic therapy.

"For example, the Batesonian phrase 'a difference that makes a difference' is very difficult, if not impossible to properly translate into Romanian – of course, this may only be a problem in a training context, not in therapy. In response to the Romanian or Hungarian translation of the question: ‘And how has this been a problem for you?’ clients almost invariably demonstrate a lack of comprehension: ‘Would you please say that again? I didn’t understand.’ The difficulty here is not that the question makes no sense, but that it is culturally unusual – and therefore potentially therapeutic," they write (Context 2007)

"Also, certain words that might sound neutral in the West sometimes trigger strong emotions in our country. For example, monitoring progress on a 1-10 scale might recall painful experiences connected with school, because in Romania, marks are from 1 to 10. Also, talking about ‘systems’ may trigger discomfort, as this is the word people used during communism to describe the oppressive dictatorial regime. People who challenged the dominant ideas used to be called ‘the enemies of the system.’ "

The communist ideal of "systemization" broke families. Women were encouraged to give birth in a pronatal policy that resulted in orphans and unwanted children. After the 1989 revolution, more than 300,000 Romanians were living in psychiatric institutions. Communist factories were closed, and displaced workers had no place. Raising a voice against the regime risked imprisonment as an enemy of the system. The word "system" is associated with oppression in Romania.

Are there lessons for us in the West? I think the answer is yes and that the Romanian experience highlights several imperatives that are useful for Western mental health professionals. Among those imperatives:

• Family psychiatry needs to agree on a definition of family therapy. Is it any approach that includes families? Do we need to be systemic to be considered family therapists? Does family support qualify as family therapy? Does family psychoeducation qualify as family therapy? Can we embrace these two levels, as well as a third, more-skilled level, a systemic family therapy? Can we accept a three-level definition of family treatment?

• Can we incorporate all the family therapy models into one approach that people will recognize as a generic approach to families? Can we use the common factors approach described by Douglas H. Sprenkle, Ph.D., Sean D. Davis, Ph.D., and Jay L. Lebow, Ph.D., in "Common Factors in Couple and Family Therapy" (New York: The Guilford Press, 2009)? For couples and family therapists, common factors over and above the well-recognized individual psychotherapy factors are conceptualizing the problems in relational terms, using therapy that aims to disrupt dysfunctional relational patterns, expanding treatment to include family members of the index patient, and fostering an expanded therapeutic alliance, according to Dr. Sprenkle, Dr. Davis, and Dr. Lebow.

• Can we develop a protocol that beginners can follow? Aaron Beck’s cognitive-behavioral therapy (CBT) provides a basic template that is easy for the novice therapist and the patient to use, yet brings a unique perspective to psychotherapy. CBT has gone on to develop in several diverse directions, but all CBT models have the same basic set of beliefs. Can a family approach or protocol be both simple AND allow for more sophisticated elaboration? Can we develop a set of basic steps that define family treatment?

• Should there be an approach to families that all disciplines can follow? Family therapy is practiced by physicians, nurses, social workers, and marriage and family therapists. Each discipline tends to work with different populations. Physicians tend to see families in which one person is the identified patient. Social workers tend to see families that have been referred for social services, families who are frequently struggling with such problems as housing, financial, and legal difficulties. Marriage and family therapists are often employed by community and hospital agencies as health care extenders and might work alongside other health care professionals. Would a single approach to families be useful?

In summary, if family therapy is to endure, it must be teachable, translatable, and relevant across disciplines and national boundaries. The systemic paradigm is an important perspective from which all practitioners can benefit. We must continue to disseminate evidence-based family treatments and teach family principles that can be incorporated on a daily basis by all mental health professionals.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals" (New York: Routledge, 2013).

In the United States, family psychiatrists continue to deal with the fallout from the 1950s and 1960s, when the early family therapists located mental illness within the family and then touted family therapy as the cure. Families felt blamed and shied away from "family therapy."

Yet, research shows that family treatment for many psychiatric and medical illnesses, whether it is family inclusion or psychoeducation, is very effective in reducing morbidity. Stigma and fear about family involvement have resulted in family treatment lagging behind other psychotherapies in its acceptance as a valid therapeutic intervention.

As a contrast, it is therefore interesting to look at Romania, a postcommunist country, where all psychotherapies were deemed "unnecessary" under communism. According to Dr. Ileana-Mihaela Botezat-Antonescu, "Psychotherapy and psychoanalysis were known as the studies of the soul during the communist regime and went underground. Secret psychotherapy meetings were held in Sibiu and Timisoara, but after the 1989 revolution, we had access to information from abroad," she said during a presentation this year at the World Psychiatric Association meeting in Bucharest, Romania.

"In 1990, freedom occurs, but nobody tells you what to do. You cannot count on anything. It alienated people seeking help. It was a process that took time," said Dr. Botezat-Antonescu, a psychiatrist and psychoanalyst who was trained in the mid-1990s by trainers from the Dutch Psychoanalytic Association and serves as chair of the National Center for Mental Health.

Psychotherapists in Romania must somehow address the traumatic environment that lasted a generation. Young people strive to gain their sense of identity and belonging and, at the same time, are challenged with reestablishing a connection between the generations. The sense of intergenerational trauma and loss extends back to grandparents who lost their farms, houses, and social position.

An understanding of the intergenerational transmission of trauma can inform psychotherapists across the globe in their care of young people. Family therapy is a type of psychotherapy that is well suited to address this intergenerational trauma.

Psychological trauma is passed down through the generations in subtle and unspoken ways. It is important for therapists to recognize when this is occurring and work with the whole family. Family therapy that specifically addresses the intergenerational transmission of trauma can help move a family from feelings of helplessness toward resilience.

Development of family therapy

Family therapy developed in Romania through training courses in Cluj, Târgu Mures, and Timisoara. As there were no Romanian trainers, these courses were taught by family therapists from countries such as Ireland, France, and Yugoslavia. Families and trainees spoke Romanian or Hungarian, and during live supervision, simultaneous translation occurred. All courses, readings, and assignments were in English. Family therapy developed in Romania through training courses in Cluj, Târgu Mures and Timisoara.

Trainees saw families in their own work contexts, for example, psychotherapy centers; psychiatry hospitals; and community centers, such as family planning clinics and domestic violence shelters. Currently, there are 16 family therapy professional organizations (Contemp. Fam. Ther. 2013;35:275-87), including:

• Systemic Family Therapy Association in Cluj

• Association of Family Therapy in Bucharest

• Romanian Association for Family and Systemic Therapy in Timisoara

• Association Crisdu Areopagus in Timisoara

• Pro Familia – Family Therapy Association in Miercurea-Ciuc

• Association for Couple and Family Psychotherapy in Iasi

• Association for Family Counselling and Therapy in Iasi

Dr. Zoltán Kónya and Dr. Ágnes Kónya run the family therapy center in Cluj and have written about the challenges of practicing family therapy in Romania (Context 2007;92:2-4 and Contemporary Family Therapy 2013;35:1). Since family therapy training courses developed at different times, in different places, with trainers invited from different countries, the sense of what constitutes family therapy varies across Romania.

The meaning of the word "systemic" has proved particularly contentious. For some, systemic is synonymous with the Milan approach – which is based on the notion that "families are self-regulating systems that function based on self-developed rules tested over time through a process of trial and error" (Case Conceptualization in Family Therapy, Boston: Pearson, 2013). However, others consider family therapy as more than a systemic approach. Some promote systemic thinking as an all-encompassing epistemological frame for consultation with individuals, families, and organizations, but others do not attach much importance to the term "systemic."

The challenge of organizing into one Romanian family therapy institution with one outlook is great. This challenge also replicates one of the major problems in our field – the idea that family therapy means different things to different people. In Romania, well-meaning outside attempts ended up in a fractured national family therapy identity.

The Kónyas, trained by Irish family therapists, identify additional challenges of introducing family therapy into a culture unfamiliar with the concept. "The fit between systemic therapy and Romanian culture has been a concern of ours since the beginning of our training," they wrote in 2003. "There had been no tradition of people seeing psychotherapists in times of distress. Also, the vast majority of health care professionals had not even heard about family therapy. Would families come to therapy?"

They found that not only did clients come to therapy, but they also were ready to work hard when they did.

"We admire our clients’ courage in facing a series of challenges involved in the therapy process: consulting an outsider for a family problem, participating in sessions as a family, being asked unusual questions, being videotaped and, sometimes, being observed by a team and/or supervisors from abroad," they said.

In their work with patients, the Kónyas write, they have encountered difficulties tied to the use of words and phrases used in systemic therapy.

"For example, the Batesonian phrase 'a difference that makes a difference' is very difficult, if not impossible to properly translate into Romanian – of course, this may only be a problem in a training context, not in therapy. In response to the Romanian or Hungarian translation of the question: ‘And how has this been a problem for you?’ clients almost invariably demonstrate a lack of comprehension: ‘Would you please say that again? I didn’t understand.’ The difficulty here is not that the question makes no sense, but that it is culturally unusual – and therefore potentially therapeutic," they write (Context 2007)

"Also, certain words that might sound neutral in the West sometimes trigger strong emotions in our country. For example, monitoring progress on a 1-10 scale might recall painful experiences connected with school, because in Romania, marks are from 1 to 10. Also, talking about ‘systems’ may trigger discomfort, as this is the word people used during communism to describe the oppressive dictatorial regime. People who challenged the dominant ideas used to be called ‘the enemies of the system.’ "

The communist ideal of "systemization" broke families. Women were encouraged to give birth in a pronatal policy that resulted in orphans and unwanted children. After the 1989 revolution, more than 300,000 Romanians were living in psychiatric institutions. Communist factories were closed, and displaced workers had no place. Raising a voice against the regime risked imprisonment as an enemy of the system. The word "system" is associated with oppression in Romania.

Are there lessons for us in the West? I think the answer is yes and that the Romanian experience highlights several imperatives that are useful for Western mental health professionals. Among those imperatives:

• Family psychiatry needs to agree on a definition of family therapy. Is it any approach that includes families? Do we need to be systemic to be considered family therapists? Does family support qualify as family therapy? Does family psychoeducation qualify as family therapy? Can we embrace these two levels, as well as a third, more-skilled level, a systemic family therapy? Can we accept a three-level definition of family treatment?

• Can we incorporate all the family therapy models into one approach that people will recognize as a generic approach to families? Can we use the common factors approach described by Douglas H. Sprenkle, Ph.D., Sean D. Davis, Ph.D., and Jay L. Lebow, Ph.D., in "Common Factors in Couple and Family Therapy" (New York: The Guilford Press, 2009)? For couples and family therapists, common factors over and above the well-recognized individual psychotherapy factors are conceptualizing the problems in relational terms, using therapy that aims to disrupt dysfunctional relational patterns, expanding treatment to include family members of the index patient, and fostering an expanded therapeutic alliance, according to Dr. Sprenkle, Dr. Davis, and Dr. Lebow.

• Can we develop a protocol that beginners can follow? Aaron Beck’s cognitive-behavioral therapy (CBT) provides a basic template that is easy for the novice therapist and the patient to use, yet brings a unique perspective to psychotherapy. CBT has gone on to develop in several diverse directions, but all CBT models have the same basic set of beliefs. Can a family approach or protocol be both simple AND allow for more sophisticated elaboration? Can we develop a set of basic steps that define family treatment?

• Should there be an approach to families that all disciplines can follow? Family therapy is practiced by physicians, nurses, social workers, and marriage and family therapists. Each discipline tends to work with different populations. Physicians tend to see families in which one person is the identified patient. Social workers tend to see families that have been referred for social services, families who are frequently struggling with such problems as housing, financial, and legal difficulties. Marriage and family therapists are often employed by community and hospital agencies as health care extenders and might work alongside other health care professionals. Would a single approach to families be useful?

In summary, if family therapy is to endure, it must be teachable, translatable, and relevant across disciplines and national boundaries. The systemic paradigm is an important perspective from which all practitioners can benefit. We must continue to disseminate evidence-based family treatments and teach family principles that can be incorporated on a daily basis by all mental health professionals.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals" (New York: Routledge, 2013).

In the United States, family psychiatrists continue to deal with the fallout from the 1950s and 1960s, when the early family therapists located mental illness within the family and then touted family therapy as the cure. Families felt blamed and shied away from "family therapy."

Yet, research shows that family treatment for many psychiatric and medical illnesses, whether it is family inclusion or psychoeducation, is very effective in reducing morbidity. Stigma and fear about family involvement have resulted in family treatment lagging behind other psychotherapies in its acceptance as a valid therapeutic intervention.

As a contrast, it is therefore interesting to look at Romania, a postcommunist country, where all psychotherapies were deemed "unnecessary" under communism. According to Dr. Ileana-Mihaela Botezat-Antonescu, "Psychotherapy and psychoanalysis were known as the studies of the soul during the communist regime and went underground. Secret psychotherapy meetings were held in Sibiu and Timisoara, but after the 1989 revolution, we had access to information from abroad," she said during a presentation this year at the World Psychiatric Association meeting in Bucharest, Romania.

"In 1990, freedom occurs, but nobody tells you what to do. You cannot count on anything. It alienated people seeking help. It was a process that took time," said Dr. Botezat-Antonescu, a psychiatrist and psychoanalyst who was trained in the mid-1990s by trainers from the Dutch Psychoanalytic Association and serves as chair of the National Center for Mental Health.

Psychotherapists in Romania must somehow address the traumatic environment that lasted a generation. Young people strive to gain their sense of identity and belonging and, at the same time, are challenged with reestablishing a connection between the generations. The sense of intergenerational trauma and loss extends back to grandparents who lost their farms, houses, and social position.

An understanding of the intergenerational transmission of trauma can inform psychotherapists across the globe in their care of young people. Family therapy is a type of psychotherapy that is well suited to address this intergenerational trauma.

Psychological trauma is passed down through the generations in subtle and unspoken ways. It is important for therapists to recognize when this is occurring and work with the whole family. Family therapy that specifically addresses the intergenerational transmission of trauma can help move a family from feelings of helplessness toward resilience.

Development of family therapy

Family therapy developed in Romania through training courses in Cluj, Târgu Mures, and Timisoara. As there were no Romanian trainers, these courses were taught by family therapists from countries such as Ireland, France, and Yugoslavia. Families and trainees spoke Romanian or Hungarian, and during live supervision, simultaneous translation occurred. All courses, readings, and assignments were in English. Family therapy developed in Romania through training courses in Cluj, Târgu Mures and Timisoara.

Trainees saw families in their own work contexts, for example, psychotherapy centers; psychiatry hospitals; and community centers, such as family planning clinics and domestic violence shelters. Currently, there are 16 family therapy professional organizations (Contemp. Fam. Ther. 2013;35:275-87), including:

• Systemic Family Therapy Association in Cluj

• Association of Family Therapy in Bucharest

• Romanian Association for Family and Systemic Therapy in Timisoara

• Association Crisdu Areopagus in Timisoara

• Pro Familia – Family Therapy Association in Miercurea-Ciuc

• Association for Couple and Family Psychotherapy in Iasi

• Association for Family Counselling and Therapy in Iasi

Dr. Zoltán Kónya and Dr. Ágnes Kónya run the family therapy center in Cluj and have written about the challenges of practicing family therapy in Romania (Context 2007;92:2-4 and Contemporary Family Therapy 2013;35:1). Since family therapy training courses developed at different times, in different places, with trainers invited from different countries, the sense of what constitutes family therapy varies across Romania.

The meaning of the word "systemic" has proved particularly contentious. For some, systemic is synonymous with the Milan approach – which is based on the notion that "families are self-regulating systems that function based on self-developed rules tested over time through a process of trial and error" (Case Conceptualization in Family Therapy, Boston: Pearson, 2013). However, others consider family therapy as more than a systemic approach. Some promote systemic thinking as an all-encompassing epistemological frame for consultation with individuals, families, and organizations, but others do not attach much importance to the term "systemic."

The challenge of organizing into one Romanian family therapy institution with one outlook is great. This challenge also replicates one of the major problems in our field – the idea that family therapy means different things to different people. In Romania, well-meaning outside attempts ended up in a fractured national family therapy identity.

The Kónyas, trained by Irish family therapists, identify additional challenges of introducing family therapy into a culture unfamiliar with the concept. "The fit between systemic therapy and Romanian culture has been a concern of ours since the beginning of our training," they wrote in 2003. "There had been no tradition of people seeing psychotherapists in times of distress. Also, the vast majority of health care professionals had not even heard about family therapy. Would families come to therapy?"

They found that not only did clients come to therapy, but they also were ready to work hard when they did.

"We admire our clients’ courage in facing a series of challenges involved in the therapy process: consulting an outsider for a family problem, participating in sessions as a family, being asked unusual questions, being videotaped and, sometimes, being observed by a team and/or supervisors from abroad," they said.

In their work with patients, the Kónyas write, they have encountered difficulties tied to the use of words and phrases used in systemic therapy.

"For example, the Batesonian phrase 'a difference that makes a difference' is very difficult, if not impossible to properly translate into Romanian – of course, this may only be a problem in a training context, not in therapy. In response to the Romanian or Hungarian translation of the question: ‘And how has this been a problem for you?’ clients almost invariably demonstrate a lack of comprehension: ‘Would you please say that again? I didn’t understand.’ The difficulty here is not that the question makes no sense, but that it is culturally unusual – and therefore potentially therapeutic," they write (Context 2007)

"Also, certain words that might sound neutral in the West sometimes trigger strong emotions in our country. For example, monitoring progress on a 1-10 scale might recall painful experiences connected with school, because in Romania, marks are from 1 to 10. Also, talking about ‘systems’ may trigger discomfort, as this is the word people used during communism to describe the oppressive dictatorial regime. People who challenged the dominant ideas used to be called ‘the enemies of the system.’ "

The communist ideal of "systemization" broke families. Women were encouraged to give birth in a pronatal policy that resulted in orphans and unwanted children. After the 1989 revolution, more than 300,000 Romanians were living in psychiatric institutions. Communist factories were closed, and displaced workers had no place. Raising a voice against the regime risked imprisonment as an enemy of the system. The word "system" is associated with oppression in Romania.

Are there lessons for us in the West? I think the answer is yes and that the Romanian experience highlights several imperatives that are useful for Western mental health professionals. Among those imperatives:

• Family psychiatry needs to agree on a definition of family therapy. Is it any approach that includes families? Do we need to be systemic to be considered family therapists? Does family support qualify as family therapy? Does family psychoeducation qualify as family therapy? Can we embrace these two levels, as well as a third, more-skilled level, a systemic family therapy? Can we accept a three-level definition of family treatment?

• Can we incorporate all the family therapy models into one approach that people will recognize as a generic approach to families? Can we use the common factors approach described by Douglas H. Sprenkle, Ph.D., Sean D. Davis, Ph.D., and Jay L. Lebow, Ph.D., in "Common Factors in Couple and Family Therapy" (New York: The Guilford Press, 2009)? For couples and family therapists, common factors over and above the well-recognized individual psychotherapy factors are conceptualizing the problems in relational terms, using therapy that aims to disrupt dysfunctional relational patterns, expanding treatment to include family members of the index patient, and fostering an expanded therapeutic alliance, according to Dr. Sprenkle, Dr. Davis, and Dr. Lebow.

• Can we develop a protocol that beginners can follow? Aaron Beck’s cognitive-behavioral therapy (CBT) provides a basic template that is easy for the novice therapist and the patient to use, yet brings a unique perspective to psychotherapy. CBT has gone on to develop in several diverse directions, but all CBT models have the same basic set of beliefs. Can a family approach or protocol be both simple AND allow for more sophisticated elaboration? Can we develop a set of basic steps that define family treatment?

• Should there be an approach to families that all disciplines can follow? Family therapy is practiced by physicians, nurses, social workers, and marriage and family therapists. Each discipline tends to work with different populations. Physicians tend to see families in which one person is the identified patient. Social workers tend to see families that have been referred for social services, families who are frequently struggling with such problems as housing, financial, and legal difficulties. Marriage and family therapists are often employed by community and hospital agencies as health care extenders and might work alongside other health care professionals. Would a single approach to families be useful?

In summary, if family therapy is to endure, it must be teachable, translatable, and relevant across disciplines and national boundaries. The systemic paradigm is an important perspective from which all practitioners can benefit. We must continue to disseminate evidence-based family treatments and teach family principles that can be incorporated on a daily basis by all mental health professionals.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals" (New York: Routledge, 2013).

A supplement to Ob.Gyn. News. This supplement was sponsored by CORD:USE Cord Blood Bank, Inc.

Faculty/Faculty Disclosure

Robert N. Wolfson, MD, PhD, FACOG, FAIUM

Specialists in Women’s Health, LLC

Colorado Springs, Colorado

Dr Wolfson has nothing to disclose.

Copyright  ©2013 by Frontline Medical Communications Inc.

To view the supplement, click the image above.

A supplement to Ob.Gyn. News. This supplement was sponsored by CORD:USE Cord Blood Bank, Inc.

Faculty/Faculty Disclosure

Robert N. Wolfson, MD, PhD, FACOG, FAIUM

Specialists in Women’s Health, LLC

Colorado Springs, Colorado

Dr Wolfson has nothing to disclose.

Copyright  ©2013 by Frontline Medical Communications Inc.

To view the supplement, click the image above.

A supplement to Ob.Gyn. News. This supplement was sponsored by CORD:USE Cord Blood Bank, Inc.

Faculty/Faculty Disclosure

Robert N. Wolfson, MD, PhD, FACOG, FAIUM

Specialists in Women’s Health, LLC

Colorado Springs, Colorado

Dr Wolfson has nothing to disclose.

Copyright  ©2013 by Frontline Medical Communications Inc.

To view the supplement, click the image above.

Please submit your short meeting reports, comings and goings, upcoming meetings, obituary announcements, etc., to From the Vascular Community in care of vascularspecialist@frontlinemedcom.com.

Meeting News

Reports

The South-Asian Association for Vascular Surgery (SAAVS) held their second annual meeting on May 30, 2013. Founded in 2011, the SAAVS is a member organization of the SVS with a mission to promote vascular health and disseminate the latest in vascular surgical techniques throughout South Asia. In just 2 years, the SAAVS has 100 registered members including 23 from overseas. During the meeting, Dr. Anil Hingorani began his tenure as President and Dr. Dipankar Mukherjee was voted President-Elect. Dr. Anahit Dua was presented an $800 prize for the outstanding resident research award. Dr. Krishna Jain and Dr. Bhagwan Satiani spoke on current issues facing vascular surgeons in the United States while Dr. Kumud Rai and Dr. Ramesh Tripathi spoke on the status of the field in India. The SAAVS is focusing its energy on establishing a "vascular update" with a 2-week didactic and practical course in South Asia. It is actively partnering with vascular societies in India to fulfill its mission. Medical students, trainees, and vascular surgeons from all backgrounds and geographic areas who are interested in advancing vascular care in South Asia are welcome to join. Visit http://saavsociety.org for more information.

Upcoming

The Canadian Society for Vascular Surgery will be holding its annual meeting September 13-14, 2013, at The Westin Edmonton, Edmonton, Alberta, Canada. The invited guest speaker is Dr. Ronald Lee Dalman II, who is the Dr. Walter C. Chidester Professor of Surgery, at Stanford University School of Medicine. Visit http://canadianvascular.ca for more details.

Obituaries

As we are beginning this new section, we are including obituaries from 2012.

Harold Clifton Urschel, Jr.

Dr. Urschel passed away on Nov. 12, 2012, at the age of 82. At the time of his death he was at the American Heart Association meeting in Los Angeles, where he was presenting material on his latest research interest: the use of stem cells for the treatment of heart failure. He was the past president of the Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, the American College of Chest Physicians, and the Texas Surgical Association and a Distinguished fellow of the Society for Vascular Surgery. He has been a Governor of the American College of Surgeons, Chairman of the American Board of Thoracic Surgery, Chairman of the Residency Review Committee for Thoracic Surgery and also a member of every important national and international medical and surgical society.

Max R. Gaspar

Dr. Gaspar, an internationally reputed vascular surgeon, died Oct. 7, 2012. He was 97. Gaspar, formerly of Long Beach, had been chief of vascular surgery for 25 years at Los Angeles County-USC Medical Center, where he also served as attending surgeon for 50 years. He had a practice in Long Beach and had also performed surgeries at St. Mary Medical Center, Memorial Medical Center, and Community Medical. He attended the University of South Dakota Medical School but finished his training at USC in 1938, and earned his M.D. in 1940. During World War II, he served in the Navy as a doctor in the Pacific. Dr. Gaspar remained active in medicine and teaching. About 17 years ago, USC established the Max R. Gaspar Symposium, which addressed a specific topic of interest to physicians and surgeons who care for patients with vascular disease. He also authored numerous articles and contributed about 14 chapters to various texts. He was one of the early pioneers in our field.

Edwin Salzman

Dr. Salzman, a professor of surgery emeritus at Harvard Medical School, died Oct. 3, 2012, at Beth Israel Deaconess Medical Center, in a room not far from his old office. His surgical career was cut short by Parkinson’s disease in the mid-1970s. Turning full attention to the scientific research that had always been his parallel career, he helped pioneer using aspirin to prevent DVT and spent a dozen years working part-time as deputy editor of the New England Journal of Medicine. Along with the findings in the 1970s about aspirin, he made significant contributions to research involving heparin and other methods that prevent postoperative pulmonary embolism.

Geoffrey Hamilton White

Dr. White died peacefully in Australia on Jan. 26, 2012, at the age of 60. He was at UCLA from 1984 to 1989 as Assistant Professor of Surgery at the UCLA School of Medicine and Chief of Vascular Surgery at the VA Wadsworth Medical Center. He was later appointed head of the department at Royal Prince Alfred Hospital and Professor of Vascular Surgery at Macquarie University Hospital, both in Australia. He had a richly deserved international reputation for his many contributions to the development of the endovascular treatment abdominal aortic aneurysms. He also coined the term "endoleak," which is nowpart of the nomenclature.

Deceased Members

(Reported to the SVS as of April 19, 2013; presented in order of receiving):

• Johann Ehrenhaft, MD Iowa City, IA

• J. Harold Harrison, MD Bartow, GA

• George Kish, MD Henderson, NV

• Malcolm Thomas, MD Phoenix, AZ

• Norman Rosenberg, MD Lantana, FL

• Michael Seremetis, MD Washington, DC

• Andrew Michalski, MD St. Catherines, Ontario, Canada

• Dean Wasserman, MD Paramus, NJ

• Duncan W. Campbell, MD Tucson, AZ

• Edwin Salzman, MD Cambridge, MA

• John Vander Woude, MD Sioux Falls, SD

• William A. Holbrook, MD Chevy Chase, MD

• Lewis H. Bosher, MD Richmond, VA

• Joseph Graham, MD Joplin, MO

• William D. Byrne McLean, VA

• John Waldhausen, MD Lemoyne, PA

• David Wulkan, MD Boca Raton, FL

• Max Gaspar, MD Seal Beach, CA

• Hugh E. Stephenson, MD Columbia, MO

• Harold C. Urschel, Jr., MD Dallas, TX

• Geoffrey H. White, MD Sydney, Australia

• Henning Loeprecht, MD Augsburg, Germany

Please submit your short meeting reports, comings and goings, upcoming meetings, obituary announcements, etc., to From the Vascular Community in care of vascularspecialist@frontlinemedcom.com.

Meeting News

Reports

The South-Asian Association for Vascular Surgery (SAAVS) held their second annual meeting on May 30, 2013. Founded in 2011, the SAAVS is a member organization of the SVS with a mission to promote vascular health and disseminate the latest in vascular surgical techniques throughout South Asia. In just 2 years, the SAAVS has 100 registered members including 23 from overseas. During the meeting, Dr. Anil Hingorani began his tenure as President and Dr. Dipankar Mukherjee was voted President-Elect. Dr. Anahit Dua was presented an $800 prize for the outstanding resident research award. Dr. Krishna Jain and Dr. Bhagwan Satiani spoke on current issues facing vascular surgeons in the United States while Dr. Kumud Rai and Dr. Ramesh Tripathi spoke on the status of the field in India. The SAAVS is focusing its energy on establishing a "vascular update" with a 2-week didactic and practical course in South Asia. It is actively partnering with vascular societies in India to fulfill its mission. Medical students, trainees, and vascular surgeons from all backgrounds and geographic areas who are interested in advancing vascular care in South Asia are welcome to join. Visit http://saavsociety.org for more information.

Upcoming

The Canadian Society for Vascular Surgery will be holding its annual meeting September 13-14, 2013, at The Westin Edmonton, Edmonton, Alberta, Canada. The invited guest speaker is Dr. Ronald Lee Dalman II, who is the Dr. Walter C. Chidester Professor of Surgery, at Stanford University School of Medicine. Visit http://canadianvascular.ca for more details.

Obituaries

As we are beginning this new section, we are including obituaries from 2012.

Harold Clifton Urschel, Jr.

Dr. Urschel passed away on Nov. 12, 2012, at the age of 82. At the time of his death he was at the American Heart Association meeting in Los Angeles, where he was presenting material on his latest research interest: the use of stem cells for the treatment of heart failure. He was the past president of the Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, the American College of Chest Physicians, and the Texas Surgical Association and a Distinguished fellow of the Society for Vascular Surgery. He has been a Governor of the American College of Surgeons, Chairman of the American Board of Thoracic Surgery, Chairman of the Residency Review Committee for Thoracic Surgery and also a member of every important national and international medical and surgical society.

Max R. Gaspar

Dr. Gaspar, an internationally reputed vascular surgeon, died Oct. 7, 2012. He was 97. Gaspar, formerly of Long Beach, had been chief of vascular surgery for 25 years at Los Angeles County-USC Medical Center, where he also served as attending surgeon for 50 years. He had a practice in Long Beach and had also performed surgeries at St. Mary Medical Center, Memorial Medical Center, and Community Medical. He attended the University of South Dakota Medical School but finished his training at USC in 1938, and earned his M.D. in 1940. During World War II, he served in the Navy as a doctor in the Pacific. Dr. Gaspar remained active in medicine and teaching. About 17 years ago, USC established the Max R. Gaspar Symposium, which addressed a specific topic of interest to physicians and surgeons who care for patients with vascular disease. He also authored numerous articles and contributed about 14 chapters to various texts. He was one of the early pioneers in our field.

Edwin Salzman

Dr. Salzman, a professor of surgery emeritus at Harvard Medical School, died Oct. 3, 2012, at Beth Israel Deaconess Medical Center, in a room not far from his old office. His surgical career was cut short by Parkinson’s disease in the mid-1970s. Turning full attention to the scientific research that had always been his parallel career, he helped pioneer using aspirin to prevent DVT and spent a dozen years working part-time as deputy editor of the New England Journal of Medicine. Along with the findings in the 1970s about aspirin, he made significant contributions to research involving heparin and other methods that prevent postoperative pulmonary embolism.

Geoffrey Hamilton White

Dr. White died peacefully in Australia on Jan. 26, 2012, at the age of 60. He was at UCLA from 1984 to 1989 as Assistant Professor of Surgery at the UCLA School of Medicine and Chief of Vascular Surgery at the VA Wadsworth Medical Center. He was later appointed head of the department at Royal Prince Alfred Hospital and Professor of Vascular Surgery at Macquarie University Hospital, both in Australia. He had a richly deserved international reputation for his many contributions to the development of the endovascular treatment abdominal aortic aneurysms. He also coined the term "endoleak," which is nowpart of the nomenclature.

Deceased Members

(Reported to the SVS as of April 19, 2013; presented in order of receiving):

• Johann Ehrenhaft, MD Iowa City, IA

• J. Harold Harrison, MD Bartow, GA

• George Kish, MD Henderson, NV

• Malcolm Thomas, MD Phoenix, AZ

• Norman Rosenberg, MD Lantana, FL

• Michael Seremetis, MD Washington, DC

• Andrew Michalski, MD St. Catherines, Ontario, Canada

• Dean Wasserman, MD Paramus, NJ

• Duncan W. Campbell, MD Tucson, AZ

• Edwin Salzman, MD Cambridge, MA

• John Vander Woude, MD Sioux Falls, SD

• William A. Holbrook, MD Chevy Chase, MD

• Lewis H. Bosher, MD Richmond, VA

• Joseph Graham, MD Joplin, MO

• William D. Byrne McLean, VA

• John Waldhausen, MD Lemoyne, PA

• David Wulkan, MD Boca Raton, FL

• Max Gaspar, MD Seal Beach, CA

• Hugh E. Stephenson, MD Columbia, MO

• Harold C. Urschel, Jr., MD Dallas, TX

• Geoffrey H. White, MD Sydney, Australia

• Henning Loeprecht, MD Augsburg, Germany

Please submit your short meeting reports, comings and goings, upcoming meetings, obituary announcements, etc., to From the Vascular Community in care of vascularspecialist@frontlinemedcom.com.

Meeting News

Reports

The South-Asian Association for Vascular Surgery (SAAVS) held their second annual meeting on May 30, 2013. Founded in 2011, the SAAVS is a member organization of the SVS with a mission to promote vascular health and disseminate the latest in vascular surgical techniques throughout South Asia. In just 2 years, the SAAVS has 100 registered members including 23 from overseas. During the meeting, Dr. Anil Hingorani began his tenure as President and Dr. Dipankar Mukherjee was voted President-Elect. Dr. Anahit Dua was presented an $800 prize for the outstanding resident research award. Dr. Krishna Jain and Dr. Bhagwan Satiani spoke on current issues facing vascular surgeons in the United States while Dr. Kumud Rai and Dr. Ramesh Tripathi spoke on the status of the field in India. The SAAVS is focusing its energy on establishing a "vascular update" with a 2-week didactic and practical course in South Asia. It is actively partnering with vascular societies in India to fulfill its mission. Medical students, trainees, and vascular surgeons from all backgrounds and geographic areas who are interested in advancing vascular care in South Asia are welcome to join. Visit http://saavsociety.org for more information.

Upcoming

The Canadian Society for Vascular Surgery will be holding its annual meeting September 13-14, 2013, at The Westin Edmonton, Edmonton, Alberta, Canada. The invited guest speaker is Dr. Ronald Lee Dalman II, who is the Dr. Walter C. Chidester Professor of Surgery, at Stanford University School of Medicine. Visit http://canadianvascular.ca for more details.

Obituaries

As we are beginning this new section, we are including obituaries from 2012.

Harold Clifton Urschel, Jr.

Dr. Urschel passed away on Nov. 12, 2012, at the age of 82. At the time of his death he was at the American Heart Association meeting in Los Angeles, where he was presenting material on his latest research interest: the use of stem cells for the treatment of heart failure. He was the past president of the Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, the American College of Chest Physicians, and the Texas Surgical Association and a Distinguished fellow of the Society for Vascular Surgery. He has been a Governor of the American College of Surgeons, Chairman of the American Board of Thoracic Surgery, Chairman of the Residency Review Committee for Thoracic Surgery and also a member of every important national and international medical and surgical society.

Max R. Gaspar

Dr. Gaspar, an internationally reputed vascular surgeon, died Oct. 7, 2012. He was 97. Gaspar, formerly of Long Beach, had been chief of vascular surgery for 25 years at Los Angeles County-USC Medical Center, where he also served as attending surgeon for 50 years. He had a practice in Long Beach and had also performed surgeries at St. Mary Medical Center, Memorial Medical Center, and Community Medical. He attended the University of South Dakota Medical School but finished his training at USC in 1938, and earned his M.D. in 1940. During World War II, he served in the Navy as a doctor in the Pacific. Dr. Gaspar remained active in medicine and teaching. About 17 years ago, USC established the Max R. Gaspar Symposium, which addressed a specific topic of interest to physicians and surgeons who care for patients with vascular disease. He also authored numerous articles and contributed about 14 chapters to various texts. He was one of the early pioneers in our field.

Edwin Salzman

Dr. Salzman, a professor of surgery emeritus at Harvard Medical School, died Oct. 3, 2012, at Beth Israel Deaconess Medical Center, in a room not far from his old office. His surgical career was cut short by Parkinson’s disease in the mid-1970s. Turning full attention to the scientific research that had always been his parallel career, he helped pioneer using aspirin to prevent DVT and spent a dozen years working part-time as deputy editor of the New England Journal of Medicine. Along with the findings in the 1970s about aspirin, he made significant contributions to research involving heparin and other methods that prevent postoperative pulmonary embolism.

Geoffrey Hamilton White

Dr. White died peacefully in Australia on Jan. 26, 2012, at the age of 60. He was at UCLA from 1984 to 1989 as Assistant Professor of Surgery at the UCLA School of Medicine and Chief of Vascular Surgery at the VA Wadsworth Medical Center. He was later appointed head of the department at Royal Prince Alfred Hospital and Professor of Vascular Surgery at Macquarie University Hospital, both in Australia. He had a richly deserved international reputation for his many contributions to the development of the endovascular treatment abdominal aortic aneurysms. He also coined the term "endoleak," which is nowpart of the nomenclature.

Deceased Members

(Reported to the SVS as of April 19, 2013; presented in order of receiving):

• Johann Ehrenhaft, MD Iowa City, IA

• J. Harold Harrison, MD Bartow, GA

• George Kish, MD Henderson, NV

• Malcolm Thomas, MD Phoenix, AZ

• Norman Rosenberg, MD Lantana, FL

• Michael Seremetis, MD Washington, DC

• Andrew Michalski, MD St. Catherines, Ontario, Canada

• Dean Wasserman, MD Paramus, NJ

• Duncan W. Campbell, MD Tucson, AZ

• Edwin Salzman, MD Cambridge, MA

• John Vander Woude, MD Sioux Falls, SD

• William A. Holbrook, MD Chevy Chase, MD

• Lewis H. Bosher, MD Richmond, VA

• Joseph Graham, MD Joplin, MO

• William D. Byrne McLean, VA

• John Waldhausen, MD Lemoyne, PA

• David Wulkan, MD Boca Raton, FL

• Max Gaspar, MD Seal Beach, CA

• Hugh E. Stephenson, MD Columbia, MO

• Harold C. Urschel, Jr., MD Dallas, TX

• Geoffrey H. White, MD Sydney, Australia

• Henning Loeprecht, MD Augsburg, Germany

Many of us will do anything or use any product available to stop oozing from suture needle holes. After all, waiting for bleeding to stop is usually not something most vascular surgeons enjoy. Most hemostatic agents are quite expensive and some don’t work very well at all.

Courtesy of Dr. Russell Samson

Our group has found a cheap alternative that is freely available in every OR and, although not perfect, works well enough in most cases – the standard ultrasonic transmission Doppler gel that you use to listen to arteries in the operative field. We usually have these available in sterile packets (Fig. 1). We cut off one end and squeeze the contents as a large glob onto the patch or anastomosis (Fig. 2). Presumably the weight of the material is enough to stop the needle-hole bleeds.

Active bleeding will usually only occur between stitches and is evidence that another stitch would be prudent. Since the gel is clear, any bleeding is easily seen. We routinely also use protamine reversal for our carotid artery endarterectomies and bypasses and so we leave the jelly on until all the protamine has been given. By that time, the bleeding has almost always stopped.

Co urtesy of Dr. Russell Samson

The jelly can be sucked away (it makes a great sounding noise in the suction!) or just diluted out with saline. I do note on the package insert that Doppler gel is not for internal use, and it is not FDA approved for this indication, but I believe we all use it anyway?

Dr. Samson is a clinical associate professor of surgery (vascular), Florida State University Medical School and a member of Sarasota Vascular Specialists, Sarasota, Fl., and the Medical Editor of Vascular Specialist.

[Editor’s Note: Please submit your own helpful tips and tricks for inclusion in this column to [email protected].]

Many of us will do anything or use any product available to stop oozing from suture needle holes. After all, waiting for bleeding to stop is usually not something most vascular surgeons enjoy. Most hemostatic agents are quite expensive and some don’t work very well at all.

Courtesy of Dr. Russell Samson

Our group has found a cheap alternative that is freely available in every OR and, although not perfect, works well enough in most cases – the standard ultrasonic transmission Doppler gel that you use to listen to arteries in the operative field. We usually have these available in sterile packets (Fig. 1). We cut off one end and squeeze the contents as a large glob onto the patch or anastomosis (Fig. 2). Presumably the weight of the material is enough to stop the needle-hole bleeds.

Active bleeding will usually only occur between stitches and is evidence that another stitch would be prudent. Since the gel is clear, any bleeding is easily seen. We routinely also use protamine reversal for our carotid artery endarterectomies and bypasses and so we leave the jelly on until all the protamine has been given. By that time, the bleeding has almost always stopped.

Co urtesy of Dr. Russell Samson

The jelly can be sucked away (it makes a great sounding noise in the suction!) or just diluted out with saline. I do note on the package insert that Doppler gel is not for internal use, and it is not FDA approved for this indication, but I believe we all use it anyway?

Dr. Samson is a clinical associate professor of surgery (vascular), Florida State University Medical School and a member of Sarasota Vascular Specialists, Sarasota, Fl., and the Medical Editor of Vascular Specialist.

[Editor’s Note: Please submit your own helpful tips and tricks for inclusion in this column to [email protected].]

Many of us will do anything or use any product available to stop oozing from suture needle holes. After all, waiting for bleeding to stop is usually not something most vascular surgeons enjoy. Most hemostatic agents are quite expensive and some don’t work very well at all.

Courtesy of Dr. Russell Samson

Our group has found a cheap alternative that is freely available in every OR and, although not perfect, works well enough in most cases – the standard ultrasonic transmission Doppler gel that you use to listen to arteries in the operative field. We usually have these available in sterile packets (Fig. 1). We cut off one end and squeeze the contents as a large glob onto the patch or anastomosis (Fig. 2). Presumably the weight of the material is enough to stop the needle-hole bleeds.

Active bleeding will usually only occur between stitches and is evidence that another stitch would be prudent. Since the gel is clear, any bleeding is easily seen. We routinely also use protamine reversal for our carotid artery endarterectomies and bypasses and so we leave the jelly on until all the protamine has been given. By that time, the bleeding has almost always stopped.

Co urtesy of Dr. Russell Samson

The jelly can be sucked away (it makes a great sounding noise in the suction!) or just diluted out with saline. I do note on the package insert that Doppler gel is not for internal use, and it is not FDA approved for this indication, but I believe we all use it anyway?

Dr. Samson is a clinical associate professor of surgery (vascular), Florida State University Medical School and a member of Sarasota Vascular Specialists, Sarasota, Fl., and the Medical Editor of Vascular Specialist.

[Editor’s Note: Please submit your own helpful tips and tricks for inclusion in this column to [email protected].]

AT 31 2/7 WEEKS' GESTATION, a woman was admitted to the hospital for hypertension. A maternal-fetal medicine specialist determined that a vaginal delivery was reasonable as long as the mother and fetus remained clinically stable; a cesarean delivery would be required if the status changed. An ObGyn and nurse midwife took over the mother’s care. Before dinoprostone and oxytocin were administered the next morning, a second ObGyn conducted a vaginal exam and found the mother’s cervix to be 4-cm dilated. After noon, the fetal heart rate became nonreassuring, with late and prolonged variable decelerations. The baby was born shortly after 5:00 pm with the umbilical cord wrapped around his neck. He was pale, lifeless, and had Apgar scores of 4 and 7 at 1 and 5 minutes, respectively. He required initial positive pressure ventilation due to bradycardia and poor respiratory effort.
The boy has cerebral palsy; although not cognitively impaired, he is severely physically handicapped. He has had several operations because one leg is shorter than the other. He has 65% function of his arms, making it impossible for him to complete normal, daily tasks by himself.

PARENTS' CLAIM A cesarean delivery should have been performed 3 hours earlier.

DEFENDANT' DEFENSE Fetal heart-rate monitoring was reassuring during the last 40 minutes of labor. An Apgar score of 7 at 5 minutes is normal. Blood gases taken at birth were normal (7.3 pH). Ultrasonography of the baby’s head at age 3 days showed normal findings. Problems were not evident on the head ultrasound until the child was 2 weeks of age, showing that the injury occurred after birth and was due to prematurity. Defendants included both ObGyns, the midwife, and the hospital.

VERDICT A $21 million Maryland verdict was returned, including $1 million in noneconomic damages that was reduced to $650,000 under the state cap.

PHYSICIAN APOLOGIZED: DIDN'T READ BIOPSY REPORT BEFORE SURGERY

A 34-YEAR-OLD WOMAN with a family history of breast cancer found a lump in her left breast. After fine-needle aspiration, a general surgeon diagnosed cancer and performed a double mastectomy.
At the first postoperative visit, the surgeon told the patient that she did not have breast cancer, and that the fine-needle aspiration results were negative. The surgeon apologized for never looking at the biopsy report prior to surgery, and admitted that is she had seen the report, she would have cancelled surgery.

PATIENT'S CLAIM The surgeon was negligent in performing bilateral mastectomies without first reading biopsy results.

PHYSICIAN'S DEFENSE The case was settled before trial.

VERDICT Michigan case evaluation delivered an award of $542,000, which both parties accepted.

CYSTOSCOPY BLAMED FOR URETERAL OBSTRUCTION, POOR KIDNEY FUNCTION

WHEN A 59-YEAR-OLD WOMAN underwent gynecologic surgery that included a cystoscopy, her uterers were functioning normally. During the following month, the ObGyn performed several follow-up examinations. A year later, the patient's right ureter was completely obstructed. The obstruction was repaired, but the patient lost function in her right kidney. She must take a drug to improve kidney function for the rest of her life.

PATIENT'S CLAIM The obstruction was caused by ligation that occurred during cystoscopy. The ObGyn should have diagnosed the obstruction during the weeks following surgery.

PHYSICIAN'S DEFENSE The cystoscopy was properly performed. The patient had not reported any symptoms after the procedure that suggested the presence of an obstruction. The obstruction gradually developed and could not have been diagnosed earlier.

VERDICT A New York defense verdict was returned.


INFERIOR VENA CAVA DAMAGED DURING ROBOTIC HYSTERECTOMY

A HYSTERECTOMY AND SALPINGO-OOPHORECTOMY were performed on a 64-year-old woman using the da Vinci Surgical System. The gynecologist also removed a cancerous endometrial mass and dissected the periaortic lymph nodes. When the gynecologist used the robot to lift a lymph fat pad, the inferior vena cava was injured and the patient lost 3 L of blood. After converting the laparotomy, a vascular surgeon implanted an artificial graft to repair the inferior vena cava. The patient fully recovered.

PATIENT'S CLAIM The gynecologist did not perform robotic surgery properly, and the patient was not told of all of the risks associated with robotic surgery. Due to the uncertainty regarding the graft's effectiveness, the patient developed posttraumatic stress disorder.

PHYSICIAN'S DEFENSE The vascular injury was a known risk associated with the procedure. The vena cava was not lacerated or transected: perforator veins that joined the lymph fat pad were unintentionally pulled out. The injury was most likely due to the application of pressure, not laceration by the surgical instrument.

VERDICT A $300,000 New York settlement was reached.

READ: The robot is gaining ground in gynecologic surgery. Should you be using it? A roundtable discussion with Arnold P. Advincula, MD; Cheryl B. Iglesia, MD; Rosanne M. Kho, MD; Jamal Mourad, DO; Marie Fidela R. Paraiso, MD; and Jason D. Wright, MD (April 2013)

FETAL DISTRESS CAUSED BRAIN INJURY: $13.9M

DURING THE LAST 2 HOURS OF LABOR, the mother was febrile, the baby's heart rate rose to over 160 bpm, and fetal monitoring indicated fetal distress. Oxytocin was administered to hasten delivery, but the mother's uterus became hyperstimulated. After nearly 17 hours of labor, the child was born without respirations. A video of the vaginal birth shows that the child was blue and unresponsive. The baby was resuscitated, and was subsequently found to have cerebral palsy, epilepsy, and mental retardation. At the time of trial, the 10-year-old had the mental capacity of a 3-year-old.

PARENTS' CLAIM The child suffered brain injury due to hypoxic ischemic encephalopathy. A cesarean delivery should have been performed as soon as fetal distress was evident. The doctors and nurses misread the baseline heart rate, and did not react when the baby did not recover well from the mother's contractions. Brain imaging did not show damage caused by infection or meningitis.

PHYSICIAN'S DEFENSE The girl's condition was caused by an infection or meningitis.

VERDICT A confidential settlement was reached with the midwife before the trial. The ObGyn was dismissed because he was never alerted to any problem by the labor and delivery team. A $13.9 million Georgia verdict was returned against the hospital system.

UTERINE ARTERY INJURED DURING CESAREAN DELIVERY

AFTER A SCHEDULED CESAREAN delivery, the 29-year-old mother had low blood pressure and an altered state of consciousness When she returned to the OR several hours later, her ObGyn found a uterine artery hematoma and laceration. After the laceration was clamped and sutured, uterine atony was noted and an emergency hysterectomy was performed

PATIENT'S CLAIM The mother was no longer able to bear children. The ObGyn was negligent in lacerating the uterine artery, failing to recognize the laceration during cesarean surgery, failing to properly monitor the patient after surgery, and failing to repair the artery in a timely manner. The patient's low blood pressure and altered state of consciousness should have been an indication that she had severe blood loss. The hospital's nursing staff failed to properly check her vital signs after surgery, and failed to report the abnormalities in blood pressure and consciousness to the ObGyn.

DEFENDANTS' DEFENSE The ObGyn claimed that a uterine laceration is a known risk of cesarean delivery; it can occur in the absence of negligence. The hospital also denied negligence.

VERDICT A Texas defense verdict was returned.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.versictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

AT 31 2/7 WEEKS' GESTATION, a woman was admitted to the hospital for hypertension. A maternal-fetal medicine specialist determined that a vaginal delivery was reasonable as long as the mother and fetus remained clinically stable; a cesarean delivery would be required if the status changed. An ObGyn and nurse midwife took over the mother’s care. Before dinoprostone and oxytocin were administered the next morning, a second ObGyn conducted a vaginal exam and found the mother’s cervix to be 4-cm dilated. After noon, the fetal heart rate became nonreassuring, with late and prolonged variable decelerations. The baby was born shortly after 5:00 pm with the umbilical cord wrapped around his neck. He was pale, lifeless, and had Apgar scores of 4 and 7 at 1 and 5 minutes, respectively. He required initial positive pressure ventilation due to bradycardia and poor respiratory effort.
The boy has cerebral palsy; although not cognitively impaired, he is severely physically handicapped. He has had several operations because one leg is shorter than the other. He has 65% function of his arms, making it impossible for him to complete normal, daily tasks by himself.

PARENTS' CLAIM A cesarean delivery should have been performed 3 hours earlier.

DEFENDANT' DEFENSE Fetal heart-rate monitoring was reassuring during the last 40 minutes of labor. An Apgar score of 7 at 5 minutes is normal. Blood gases taken at birth were normal (7.3 pH). Ultrasonography of the baby’s head at age 3 days showed normal findings. Problems were not evident on the head ultrasound until the child was 2 weeks of age, showing that the injury occurred after birth and was due to prematurity. Defendants included both ObGyns, the midwife, and the hospital.

VERDICT A $21 million Maryland verdict was returned, including $1 million in noneconomic damages that was reduced to $650,000 under the state cap.

PHYSICIAN APOLOGIZED: DIDN'T READ BIOPSY REPORT BEFORE SURGERY

A 34-YEAR-OLD WOMAN with a family history of breast cancer found a lump in her left breast. After fine-needle aspiration, a general surgeon diagnosed cancer and performed a double mastectomy.
At the first postoperative visit, the surgeon told the patient that she did not have breast cancer, and that the fine-needle aspiration results were negative. The surgeon apologized for never looking at the biopsy report prior to surgery, and admitted that is she had seen the report, she would have cancelled surgery.

PATIENT'S CLAIM The surgeon was negligent in performing bilateral mastectomies without first reading biopsy results.

PHYSICIAN'S DEFENSE The case was settled before trial.

VERDICT Michigan case evaluation delivered an award of $542,000, which both parties accepted.

CYSTOSCOPY BLAMED FOR URETERAL OBSTRUCTION, POOR KIDNEY FUNCTION

WHEN A 59-YEAR-OLD WOMAN underwent gynecologic surgery that included a cystoscopy, her uterers were functioning normally. During the following month, the ObGyn performed several follow-up examinations. A year later, the patient's right ureter was completely obstructed. The obstruction was repaired, but the patient lost function in her right kidney. She must take a drug to improve kidney function for the rest of her life.

PATIENT'S CLAIM The obstruction was caused by ligation that occurred during cystoscopy. The ObGyn should have diagnosed the obstruction during the weeks following surgery.

PHYSICIAN'S DEFENSE The cystoscopy was properly performed. The patient had not reported any symptoms after the procedure that suggested the presence of an obstruction. The obstruction gradually developed and could not have been diagnosed earlier.

VERDICT A New York defense verdict was returned.


INFERIOR VENA CAVA DAMAGED DURING ROBOTIC HYSTERECTOMY

A HYSTERECTOMY AND SALPINGO-OOPHORECTOMY were performed on a 64-year-old woman using the da Vinci Surgical System. The gynecologist also removed a cancerous endometrial mass and dissected the periaortic lymph nodes. When the gynecologist used the robot to lift a lymph fat pad, the inferior vena cava was injured and the patient lost 3 L of blood. After converting the laparotomy, a vascular surgeon implanted an artificial graft to repair the inferior vena cava. The patient fully recovered.

PATIENT'S CLAIM The gynecologist did not perform robotic surgery properly, and the patient was not told of all of the risks associated with robotic surgery. Due to the uncertainty regarding the graft's effectiveness, the patient developed posttraumatic stress disorder.

PHYSICIAN'S DEFENSE The vascular injury was a known risk associated with the procedure. The vena cava was not lacerated or transected: perforator veins that joined the lymph fat pad were unintentionally pulled out. The injury was most likely due to the application of pressure, not laceration by the surgical instrument.

VERDICT A $300,000 New York settlement was reached.

READ: The robot is gaining ground in gynecologic surgery. Should you be using it? A roundtable discussion with Arnold P. Advincula, MD; Cheryl B. Iglesia, MD; Rosanne M. Kho, MD; Jamal Mourad, DO; Marie Fidela R. Paraiso, MD; and Jason D. Wright, MD (April 2013)

FETAL DISTRESS CAUSED BRAIN INJURY: $13.9M

DURING THE LAST 2 HOURS OF LABOR, the mother was febrile, the baby's heart rate rose to over 160 bpm, and fetal monitoring indicated fetal distress. Oxytocin was administered to hasten delivery, but the mother's uterus became hyperstimulated. After nearly 17 hours of labor, the child was born without respirations. A video of the vaginal birth shows that the child was blue and unresponsive. The baby was resuscitated, and was subsequently found to have cerebral palsy, epilepsy, and mental retardation. At the time of trial, the 10-year-old had the mental capacity of a 3-year-old.

PARENTS' CLAIM The child suffered brain injury due to hypoxic ischemic encephalopathy. A cesarean delivery should have been performed as soon as fetal distress was evident. The doctors and nurses misread the baseline heart rate, and did not react when the baby did not recover well from the mother's contractions. Brain imaging did not show damage caused by infection or meningitis.

PHYSICIAN'S DEFENSE The girl's condition was caused by an infection or meningitis.

VERDICT A confidential settlement was reached with the midwife before the trial. The ObGyn was dismissed because he was never alerted to any problem by the labor and delivery team. A $13.9 million Georgia verdict was returned against the hospital system.

UTERINE ARTERY INJURED DURING CESAREAN DELIVERY

AFTER A SCHEDULED CESAREAN delivery, the 29-year-old mother had low blood pressure and an altered state of consciousness When she returned to the OR several hours later, her ObGyn found a uterine artery hematoma and laceration. After the laceration was clamped and sutured, uterine atony was noted and an emergency hysterectomy was performed

PATIENT'S CLAIM The mother was no longer able to bear children. The ObGyn was negligent in lacerating the uterine artery, failing to recognize the laceration during cesarean surgery, failing to properly monitor the patient after surgery, and failing to repair the artery in a timely manner. The patient's low blood pressure and altered state of consciousness should have been an indication that she had severe blood loss. The hospital's nursing staff failed to properly check her vital signs after surgery, and failed to report the abnormalities in blood pressure and consciousness to the ObGyn.

DEFENDANTS' DEFENSE The ObGyn claimed that a uterine laceration is a known risk of cesarean delivery; it can occur in the absence of negligence. The hospital also denied negligence.

VERDICT A Texas defense verdict was returned.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.versictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

AT 31 2/7 WEEKS' GESTATION, a woman was admitted to the hospital for hypertension. A maternal-fetal medicine specialist determined that a vaginal delivery was reasonable as long as the mother and fetus remained clinically stable; a cesarean delivery would be required if the status changed. An ObGyn and nurse midwife took over the mother’s care. Before dinoprostone and oxytocin were administered the next morning, a second ObGyn conducted a vaginal exam and found the mother’s cervix to be 4-cm dilated. After noon, the fetal heart rate became nonreassuring, with late and prolonged variable decelerations. The baby was born shortly after 5:00 pm with the umbilical cord wrapped around his neck. He was pale, lifeless, and had Apgar scores of 4 and 7 at 1 and 5 minutes, respectively. He required initial positive pressure ventilation due to bradycardia and poor respiratory effort.
The boy has cerebral palsy; although not cognitively impaired, he is severely physically handicapped. He has had several operations because one leg is shorter than the other. He has 65% function of his arms, making it impossible for him to complete normal, daily tasks by himself.

PARENTS' CLAIM A cesarean delivery should have been performed 3 hours earlier.

DEFENDANT' DEFENSE Fetal heart-rate monitoring was reassuring during the last 40 minutes of labor. An Apgar score of 7 at 5 minutes is normal. Blood gases taken at birth were normal (7.3 pH). Ultrasonography of the baby’s head at age 3 days showed normal findings. Problems were not evident on the head ultrasound until the child was 2 weeks of age, showing that the injury occurred after birth and was due to prematurity. Defendants included both ObGyns, the midwife, and the hospital.

VERDICT A $21 million Maryland verdict was returned, including $1 million in noneconomic damages that was reduced to $650,000 under the state cap.

PHYSICIAN APOLOGIZED: DIDN'T READ BIOPSY REPORT BEFORE SURGERY

A 34-YEAR-OLD WOMAN with a family history of breast cancer found a lump in her left breast. After fine-needle aspiration, a general surgeon diagnosed cancer and performed a double mastectomy.
At the first postoperative visit, the surgeon told the patient that she did not have breast cancer, and that the fine-needle aspiration results were negative. The surgeon apologized for never looking at the biopsy report prior to surgery, and admitted that is she had seen the report, she would have cancelled surgery.

PATIENT'S CLAIM The surgeon was negligent in performing bilateral mastectomies without first reading biopsy results.

PHYSICIAN'S DEFENSE The case was settled before trial.

VERDICT Michigan case evaluation delivered an award of $542,000, which both parties accepted.

CYSTOSCOPY BLAMED FOR URETERAL OBSTRUCTION, POOR KIDNEY FUNCTION

WHEN A 59-YEAR-OLD WOMAN underwent gynecologic surgery that included a cystoscopy, her uterers were functioning normally. During the following month, the ObGyn performed several follow-up examinations. A year later, the patient's right ureter was completely obstructed. The obstruction was repaired, but the patient lost function in her right kidney. She must take a drug to improve kidney function for the rest of her life.

PATIENT'S CLAIM The obstruction was caused by ligation that occurred during cystoscopy. The ObGyn should have diagnosed the obstruction during the weeks following surgery.

PHYSICIAN'S DEFENSE The cystoscopy was properly performed. The patient had not reported any symptoms after the procedure that suggested the presence of an obstruction. The obstruction gradually developed and could not have been diagnosed earlier.

VERDICT A New York defense verdict was returned.


INFERIOR VENA CAVA DAMAGED DURING ROBOTIC HYSTERECTOMY

A HYSTERECTOMY AND SALPINGO-OOPHORECTOMY were performed on a 64-year-old woman using the da Vinci Surgical System. The gynecologist also removed a cancerous endometrial mass and dissected the periaortic lymph nodes. When the gynecologist used the robot to lift a lymph fat pad, the inferior vena cava was injured and the patient lost 3 L of blood. After converting the laparotomy, a vascular surgeon implanted an artificial graft to repair the inferior vena cava. The patient fully recovered.

PATIENT'S CLAIM The gynecologist did not perform robotic surgery properly, and the patient was not told of all of the risks associated with robotic surgery. Due to the uncertainty regarding the graft's effectiveness, the patient developed posttraumatic stress disorder.

PHYSICIAN'S DEFENSE The vascular injury was a known risk associated with the procedure. The vena cava was not lacerated or transected: perforator veins that joined the lymph fat pad were unintentionally pulled out. The injury was most likely due to the application of pressure, not laceration by the surgical instrument.

VERDICT A $300,000 New York settlement was reached.

READ: The robot is gaining ground in gynecologic surgery. Should you be using it? A roundtable discussion with Arnold P. Advincula, MD; Cheryl B. Iglesia, MD; Rosanne M. Kho, MD; Jamal Mourad, DO; Marie Fidela R. Paraiso, MD; and Jason D. Wright, MD (April 2013)

FETAL DISTRESS CAUSED BRAIN INJURY: $13.9M

DURING THE LAST 2 HOURS OF LABOR, the mother was febrile, the baby's heart rate rose to over 160 bpm, and fetal monitoring indicated fetal distress. Oxytocin was administered to hasten delivery, but the mother's uterus became hyperstimulated. After nearly 17 hours of labor, the child was born without respirations. A video of the vaginal birth shows that the child was blue and unresponsive. The baby was resuscitated, and was subsequently found to have cerebral palsy, epilepsy, and mental retardation. At the time of trial, the 10-year-old had the mental capacity of a 3-year-old.

PARENTS' CLAIM The child suffered brain injury due to hypoxic ischemic encephalopathy. A cesarean delivery should have been performed as soon as fetal distress was evident. The doctors and nurses misread the baseline heart rate, and did not react when the baby did not recover well from the mother's contractions. Brain imaging did not show damage caused by infection or meningitis.

PHYSICIAN'S DEFENSE The girl's condition was caused by an infection or meningitis.

VERDICT A confidential settlement was reached with the midwife before the trial. The ObGyn was dismissed because he was never alerted to any problem by the labor and delivery team. A $13.9 million Georgia verdict was returned against the hospital system.

UTERINE ARTERY INJURED DURING CESAREAN DELIVERY

AFTER A SCHEDULED CESAREAN delivery, the 29-year-old mother had low blood pressure and an altered state of consciousness When she returned to the OR several hours later, her ObGyn found a uterine artery hematoma and laceration. After the laceration was clamped and sutured, uterine atony was noted and an emergency hysterectomy was performed

PATIENT'S CLAIM The mother was no longer able to bear children. The ObGyn was negligent in lacerating the uterine artery, failing to recognize the laceration during cesarean surgery, failing to properly monitor the patient after surgery, and failing to repair the artery in a timely manner. The patient's low blood pressure and altered state of consciousness should have been an indication that she had severe blood loss. The hospital's nursing staff failed to properly check her vital signs after surgery, and failed to report the abnormalities in blood pressure and consciousness to the ObGyn.

DEFENDANTS' DEFENSE The ObGyn claimed that a uterine laceration is a known risk of cesarean delivery; it can occur in the absence of negligence. The hospital also denied negligence.

VERDICT A Texas defense verdict was returned.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.versictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

Dr. Nathan D. Airhart, Washington University School of Medicine, St. Louis, was the recipient of this year’s SVS Foundation Resident Research Prize Paper, which was presented at the Vascular Annual Meeting as part of the William J. von Liebig Forum, which features the best in resident research.

Dr. Airhart, his mentor, Dr. John A. Curci, and his colleagues studied the specific contribution of the vascular smooth muscle cells (SMCs) to the destruction of the elastic proteins that are uniquely absent in the walls of abdominal aortic aneurysms (AAAs). "Although the SMC is the dominant cell type in the aortic wall, our understanding of the role of these cells in aneurysms has been very limited," said Dr. Airhart.

Courtesy Dr. John A. Curci

To directly study the function of these cells, Dr. Airhart and his colleagues embarked on an ambitious project to isolate live SMCs from AAAs, normal abdominal aorta (NAA), and plaque from carotid endarterectomy (CEA) procedures. The group profiled the mRNA produced by these cultured cells by microarray and clearly demonstrated a unique pattern of expression of the AAA-SMC.

"The mRNA profiles confirmed that the AAA cells were likely interacting with the matrix differently than the other SMCs, but it did not necessarily tell us how they were influencing aneurysm development," said Dr. Airhart. To better understand the role of these cells, the investigators evaluated the ability of these cells to break down elastic fibers in culture.

Under standard culture conditions, AAA-SMCs were able to degrade three times more elastin than the NAA-SMCs. "Even more remarkable was the finding that co-culture with activated macrophages – a cell type always found in the wall of aneurysms – resulted in a further doubling of the elastic fiber damage by the AAA-SMCs. Co-culture of macrophages with NAA-SMCs had no effect on the elastin degraded," said Dr. Airhart.

Further experiments suggested that the enzymes principally responsible for the elastolytic activity of these cells are the matrix metalloproteinases (MMPs). Increases in the production and/or activation of MMP-2 and/or MMP-9 were prominently found in cultures of AAA-SMCs.

"These studies present the strongest evidence that AAA-SMCs exhibit a disease-specific gene expression pattern and can very potently damage the elastic fiber matrix in the aortic wall. The unique and remarkable synergy with activated inflammatory cells might help explain the characteristic elastin loss of aortic aneurysms. Future studies will allow us to understand and alter the cellular mechanisms which lead to increased production and activation of elastolytic MMPs by these cells," Dr. Curci concluded.

The prestigious Resident Research Prize is intended to motivate new physicians to pursue vascular research. The prize recipient is invited to present his or her research results at the Society for Vascular Surgery’s Vascular Annual Meeting and the prize includes a 1-year subscription to the Journal of Vascular Surgery.

Dr. Nathan D. Airhart, Washington University School of Medicine, St. Louis, was the recipient of this year’s SVS Foundation Resident Research Prize Paper, which was presented at the Vascular Annual Meeting as part of the William J. von Liebig Forum, which features the best in resident research.

Dr. Airhart, his mentor, Dr. John A. Curci, and his colleagues studied the specific contribution of the vascular smooth muscle cells (SMCs) to the destruction of the elastic proteins that are uniquely absent in the walls of abdominal aortic aneurysms (AAAs). "Although the SMC is the dominant cell type in the aortic wall, our understanding of the role of these cells in aneurysms has been very limited," said Dr. Airhart.

Courtesy Dr. John A. Curci

To directly study the function of these cells, Dr. Airhart and his colleagues embarked on an ambitious project to isolate live SMCs from AAAs, normal abdominal aorta (NAA), and plaque from carotid endarterectomy (CEA) procedures. The group profiled the mRNA produced by these cultured cells by microarray and clearly demonstrated a unique pattern of expression of the AAA-SMC.

"The mRNA profiles confirmed that the AAA cells were likely interacting with the matrix differently than the other SMCs, but it did not necessarily tell us how they were influencing aneurysm development," said Dr. Airhart. To better understand the role of these cells, the investigators evaluated the ability of these cells to break down elastic fibers in culture.

Under standard culture conditions, AAA-SMCs were able to degrade three times more elastin than the NAA-SMCs. "Even more remarkable was the finding that co-culture with activated macrophages – a cell type always found in the wall of aneurysms – resulted in a further doubling of the elastic fiber damage by the AAA-SMCs. Co-culture of macrophages with NAA-SMCs had no effect on the elastin degraded," said Dr. Airhart.

Further experiments suggested that the enzymes principally responsible for the elastolytic activity of these cells are the matrix metalloproteinases (MMPs). Increases in the production and/or activation of MMP-2 and/or MMP-9 were prominently found in cultures of AAA-SMCs.

"These studies present the strongest evidence that AAA-SMCs exhibit a disease-specific gene expression pattern and can very potently damage the elastic fiber matrix in the aortic wall. The unique and remarkable synergy with activated inflammatory cells might help explain the characteristic elastin loss of aortic aneurysms. Future studies will allow us to understand and alter the cellular mechanisms which lead to increased production and activation of elastolytic MMPs by these cells," Dr. Curci concluded.

The prestigious Resident Research Prize is intended to motivate new physicians to pursue vascular research. The prize recipient is invited to present his or her research results at the Society for Vascular Surgery’s Vascular Annual Meeting and the prize includes a 1-year subscription to the Journal of Vascular Surgery.

Dr. Nathan D. Airhart, Washington University School of Medicine, St. Louis, was the recipient of this year’s SVS Foundation Resident Research Prize Paper, which was presented at the Vascular Annual Meeting as part of the William J. von Liebig Forum, which features the best in resident research.

Dr. Airhart, his mentor, Dr. John A. Curci, and his colleagues studied the specific contribution of the vascular smooth muscle cells (SMCs) to the destruction of the elastic proteins that are uniquely absent in the walls of abdominal aortic aneurysms (AAAs). "Although the SMC is the dominant cell type in the aortic wall, our understanding of the role of these cells in aneurysms has been very limited," said Dr. Airhart.

Courtesy Dr. John A. Curci

To directly study the function of these cells, Dr. Airhart and his colleagues embarked on an ambitious project to isolate live SMCs from AAAs, normal abdominal aorta (NAA), and plaque from carotid endarterectomy (CEA) procedures. The group profiled the mRNA produced by these cultured cells by microarray and clearly demonstrated a unique pattern of expression of the AAA-SMC.

"The mRNA profiles confirmed that the AAA cells were likely interacting with the matrix differently than the other SMCs, but it did not necessarily tell us how they were influencing aneurysm development," said Dr. Airhart. To better understand the role of these cells, the investigators evaluated the ability of these cells to break down elastic fibers in culture.

Under standard culture conditions, AAA-SMCs were able to degrade three times more elastin than the NAA-SMCs. "Even more remarkable was the finding that co-culture with activated macrophages – a cell type always found in the wall of aneurysms – resulted in a further doubling of the elastic fiber damage by the AAA-SMCs. Co-culture of macrophages with NAA-SMCs had no effect on the elastin degraded," said Dr. Airhart.

Further experiments suggested that the enzymes principally responsible for the elastolytic activity of these cells are the matrix metalloproteinases (MMPs). Increases in the production and/or activation of MMP-2 and/or MMP-9 were prominently found in cultures of AAA-SMCs.

"These studies present the strongest evidence that AAA-SMCs exhibit a disease-specific gene expression pattern and can very potently damage the elastic fiber matrix in the aortic wall. The unique and remarkable synergy with activated inflammatory cells might help explain the characteristic elastin loss of aortic aneurysms. Future studies will allow us to understand and alter the cellular mechanisms which lead to increased production and activation of elastolytic MMPs by these cells," Dr. Curci concluded.

The prestigious Resident Research Prize is intended to motivate new physicians to pursue vascular research. The prize recipient is invited to present his or her research results at the Society for Vascular Surgery’s Vascular Annual Meeting and the prize includes a 1-year subscription to the Journal of Vascular Surgery.

A middle aged man goes to his primary care physician for his annual check-up. Because of an abnormal physical finding or laboratory test, he is referred to a specialist, who, after additional tests, recommends an operation with considerable risks. Before agreeing to the procedure, the man decides to seek a "second opinion." This sequence of events occurs routinely as the second opinion is generally accepted as one of the sacred cows of American medical care.

Let’s examine this sacred cow to see if it is a good thing or an overrated practice that serves little useful purpose. First the potential advantages. If the second specialist agrees with the first opinion, it can be reassuring to the patient and his family, but it really is unnecessary.

On the other hand, if the original specialist is less than optimal or motivated by the financial rewards of performing his recommended procedure, the second opinion can possibly benefit the patient by saving him from an unnecessary, wrong or possibly harmful operation. However, why not solicit the opinion of the second, better specialist first.

Now the downside. If the second specialist disagrees with the first, the patient faces a dilemma. He has to pick between the two specialists. How does he do this? Does he follow the advice of the more articulate and likeable specialist? Does he pick the opinion he likes despite being a non-expert? Does he solicit a third opinion – a tie breaker? Taking a vote on a medical or scientific question does not ensure arriving at the correct answer – especially if the vote is 2:1 and especially if one of the specialists is self-appointed or a full-fledged phony. So disagreement between the first and second specialist does not ensure better care. It can lead to confusion and uncertainty. It may lead to the wrong course of action. Our second opinion process may therefore be unnecessary or misleading, and is in reality not worth much.

What should replace this flawed sacred cow? In principle it is simple, in practice not so simple. The first specialist referral should be to an exemplary medical practitioner, one whose knowledge, judgment, skill level, and motivation can be trusted. Finding such an individual is complex. Referral patterns can be flawed and based on proximity, personality or economic considerations.

Examining a "top doctors list" can also be misleading since inclusion in some of these listings can be based on flawed criteria or even payment of a fee. Similar considerations may apply to some listings of top hospitals. Moreover, not every specialist in top hospitals is expert in all aspects of his or her specialty.

The key to finding an initial exemplary specialist whose first opinion can be trusted is to have that specialist identified by another knowledgeable physician who represents the patient’s interests. Such a "physician-trustee" can be a primary care physician with whom the patient has a solid relationship.

Alternatively, it can be a physician who is a friend, relative or acquaintance. In either case the physician-trustee has to take the time and make the effort to identify specialists he knows in the field in which the patient needs care. The physician-trustee must then make the additional effort to use these contacts to identify a first-rate specialist in the field and to explore the qualities, reputation, and results of this specialist by speaking to those who have worked with him directly and know him first hand.

Making such an effort is not a casual business in today’s complex medical environment. Yet it is one for which there is no other substitute. I have done it for friends and family on a number of occasions – often for patients who live in other cities and countries. It may take a number of phone calls to individuals in my own and other specialties within my own and other institutions. It does, however, produce positive results and solve the problem.

Unfortunately many who require expert specialty care in the United States do not have access to a dependable primary care giver or a trusted physician friend or relative who can serve as a physician-trustee.

Moreover, many insurance plans discourage specialist referrals or will only cover the costs of their selected, less than optimal in-network specialists. Finally, in the U.S. health care system even under the Affordable Care Act, no financial compensation is provided for physician-trustee services and the time and effort involved.

This deficiency must be corrected since physician-trustees can provide a uniquely valuable service. They can eliminate unnecessary financially motivated procedures; they facilitate identification of genuinely superior care-givers; and they enable patients to obtain referral to a specialist whose first opinion can be counted on to be dependable and who will deliver exemplary care. They also obviate the need for flawed and unnecessary second opinions.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or Publisher.

A middle aged man goes to his primary care physician for his annual check-up. Because of an abnormal physical finding or laboratory test, he is referred to a specialist, who, after additional tests, recommends an operation with considerable risks. Before agreeing to the procedure, the man decides to seek a "second opinion." This sequence of events occurs routinely as the second opinion is generally accepted as one of the sacred cows of American medical care.

Let’s examine this sacred cow to see if it is a good thing or an overrated practice that serves little useful purpose. First the potential advantages. If the second specialist agrees with the first opinion, it can be reassuring to the patient and his family, but it really is unnecessary.

On the other hand, if the original specialist is less than optimal or motivated by the financial rewards of performing his recommended procedure, the second opinion can possibly benefit the patient by saving him from an unnecessary, wrong or possibly harmful operation. However, why not solicit the opinion of the second, better specialist first.

Now the downside. If the second specialist disagrees with the first, the patient faces a dilemma. He has to pick between the two specialists. How does he do this? Does he follow the advice of the more articulate and likeable specialist? Does he pick the opinion he likes despite being a non-expert? Does he solicit a third opinion – a tie breaker? Taking a vote on a medical or scientific question does not ensure arriving at the correct answer – especially if the vote is 2:1 and especially if one of the specialists is self-appointed or a full-fledged phony. So disagreement between the first and second specialist does not ensure better care. It can lead to confusion and uncertainty. It may lead to the wrong course of action. Our second opinion process may therefore be unnecessary or misleading, and is in reality not worth much.

What should replace this flawed sacred cow? In principle it is simple, in practice not so simple. The first specialist referral should be to an exemplary medical practitioner, one whose knowledge, judgment, skill level, and motivation can be trusted. Finding such an individual is complex. Referral patterns can be flawed and based on proximity, personality or economic considerations.

Examining a "top doctors list" can also be misleading since inclusion in some of these listings can be based on flawed criteria or even payment of a fee. Similar considerations may apply to some listings of top hospitals. Moreover, not every specialist in top hospitals is expert in all aspects of his or her specialty.

The key to finding an initial exemplary specialist whose first opinion can be trusted is to have that specialist identified by another knowledgeable physician who represents the patient’s interests. Such a "physician-trustee" can be a primary care physician with whom the patient has a solid relationship.

Alternatively, it can be a physician who is a friend, relative or acquaintance. In either case the physician-trustee has to take the time and make the effort to identify specialists he knows in the field in which the patient needs care. The physician-trustee must then make the additional effort to use these contacts to identify a first-rate specialist in the field and to explore the qualities, reputation, and results of this specialist by speaking to those who have worked with him directly and know him first hand.

Making such an effort is not a casual business in today’s complex medical environment. Yet it is one for which there is no other substitute. I have done it for friends and family on a number of occasions – often for patients who live in other cities and countries. It may take a number of phone calls to individuals in my own and other specialties within my own and other institutions. It does, however, produce positive results and solve the problem.

Unfortunately many who require expert specialty care in the United States do not have access to a dependable primary care giver or a trusted physician friend or relative who can serve as a physician-trustee.

Moreover, many insurance plans discourage specialist referrals or will only cover the costs of their selected, less than optimal in-network specialists. Finally, in the U.S. health care system even under the Affordable Care Act, no financial compensation is provided for physician-trustee services and the time and effort involved.

This deficiency must be corrected since physician-trustees can provide a uniquely valuable service. They can eliminate unnecessary financially motivated procedures; they facilitate identification of genuinely superior care-givers; and they enable patients to obtain referral to a specialist whose first opinion can be counted on to be dependable and who will deliver exemplary care. They also obviate the need for flawed and unnecessary second opinions.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or Publisher.

A middle aged man goes to his primary care physician for his annual check-up. Because of an abnormal physical finding or laboratory test, he is referred to a specialist, who, after additional tests, recommends an operation with considerable risks. Before agreeing to the procedure, the man decides to seek a "second opinion." This sequence of events occurs routinely as the second opinion is generally accepted as one of the sacred cows of American medical care.

Let’s examine this sacred cow to see if it is a good thing or an overrated practice that serves little useful purpose. First the potential advantages. If the second specialist agrees with the first opinion, it can be reassuring to the patient and his family, but it really is unnecessary.

On the other hand, if the original specialist is less than optimal or motivated by the financial rewards of performing his recommended procedure, the second opinion can possibly benefit the patient by saving him from an unnecessary, wrong or possibly harmful operation. However, why not solicit the opinion of the second, better specialist first.

Now the downside. If the second specialist disagrees with the first, the patient faces a dilemma. He has to pick between the two specialists. How does he do this? Does he follow the advice of the more articulate and likeable specialist? Does he pick the opinion he likes despite being a non-expert? Does he solicit a third opinion – a tie breaker? Taking a vote on a medical or scientific question does not ensure arriving at the correct answer – especially if the vote is 2:1 and especially if one of the specialists is self-appointed or a full-fledged phony. So disagreement between the first and second specialist does not ensure better care. It can lead to confusion and uncertainty. It may lead to the wrong course of action. Our second opinion process may therefore be unnecessary or misleading, and is in reality not worth much.

What should replace this flawed sacred cow? In principle it is simple, in practice not so simple. The first specialist referral should be to an exemplary medical practitioner, one whose knowledge, judgment, skill level, and motivation can be trusted. Finding such an individual is complex. Referral patterns can be flawed and based on proximity, personality or economic considerations.

Examining a "top doctors list" can also be misleading since inclusion in some of these listings can be based on flawed criteria or even payment of a fee. Similar considerations may apply to some listings of top hospitals. Moreover, not every specialist in top hospitals is expert in all aspects of his or her specialty.

The key to finding an initial exemplary specialist whose first opinion can be trusted is to have that specialist identified by another knowledgeable physician who represents the patient’s interests. Such a "physician-trustee" can be a primary care physician with whom the patient has a solid relationship.

Alternatively, it can be a physician who is a friend, relative or acquaintance. In either case the physician-trustee has to take the time and make the effort to identify specialists he knows in the field in which the patient needs care. The physician-trustee must then make the additional effort to use these contacts to identify a first-rate specialist in the field and to explore the qualities, reputation, and results of this specialist by speaking to those who have worked with him directly and know him first hand.

Making such an effort is not a casual business in today’s complex medical environment. Yet it is one for which there is no other substitute. I have done it for friends and family on a number of occasions – often for patients who live in other cities and countries. It may take a number of phone calls to individuals in my own and other specialties within my own and other institutions. It does, however, produce positive results and solve the problem.

Unfortunately many who require expert specialty care in the United States do not have access to a dependable primary care giver or a trusted physician friend or relative who can serve as a physician-trustee.

Moreover, many insurance plans discourage specialist referrals or will only cover the costs of their selected, less than optimal in-network specialists. Finally, in the U.S. health care system even under the Affordable Care Act, no financial compensation is provided for physician-trustee services and the time and effort involved.

This deficiency must be corrected since physician-trustees can provide a uniquely valuable service. They can eliminate unnecessary financially motivated procedures; they facilitate identification of genuinely superior care-givers; and they enable patients to obtain referral to a specialist whose first opinion can be counted on to be dependable and who will deliver exemplary care. They also obviate the need for flawed and unnecessary second opinions.

Dr. Veith is Professor of Surgery at New York University Medical Center and the Cleveland Clinic. He is an associate medical editor for Vascular Specialist.

The ideas and opinions expressed in Vascular Specialist do not necessarily reflect those of the Society or Publisher.

SAN FRANCISCO – Multiple organ dysfunction syndrome is "underappreciated" by many of today’s clinicians, as optimal ways to treat it remain elusive, said Dr. Larry H. Hollier.

At the Vascular Annual Meeting, Dr. Hollier, professor of surgery and chancellor of the Louisiana State University Health Sciences Center, New Orleans, defined multiple organ dysfunction syndrome (MODS) as altered organ functions in an acutely ill patient requiring intervention to achieve homeostasis. "That’s a pretty broad definition, but it’s one of the most common causes of death in surgical intensive care units," he said. "Numerous precipitating factors classically described in multiple organ dysfunction syndrome include sepsis, trauma, cardiac arrest, visceral ischemia, burns, pancreatitis, shock, and major surgery with postoperative instability."

IMNG Medical Media/Martin Allred

The pathophysiology of MODS "is fairly straightforward," he continued. "Some events result in ischemia and tissue hypoxia. Reperfusion occurs with the activation of cytokines, and an exaggerated inflammatory response generates oxygen free radicals, tissue damage, and then organ dysfunction." said Dr. Hollier, the invited speaker for the John Homans Lectureship of the SVS.

The major underlying issue in MODS stems from uncorrected oxygen debt in tissues. In fact, the level of perioperative tissue debt has a direct relationship on postoperative morbidity and mortality. According to Dr. Hollier, the predicted outcome by acutely accumulated oxygen debt in the first 4 hours post injury works like this: 8 L/m² leads to a severe flulike syndrome (mild SIRS); 26 L/m² leads to multiple organ dysfunction syndrome; and 33 L/m² or more leads to death. "The uncorrected oxygen debt in tissues that is initiated is not the end of it," he said. "There’s an accumulating oxygen debt that amasses to keep biomass viable during low oxygen delivery. After resuscitation, there’s increased oxygen required above the basal rate, because explosive oxygen needs occur in order to fuel the inflammation of reperfusion injury."

Conventional therapies for MODS include volume resuscitation, ionotropic agents to improve cardiac performance and increase oxygen delivery, and ventilator support to improve oxygen input. Multiple experimental therapies have also been used, but no universal treatment has been found that reverses MODS, he said. "Early diagnosis and prompt treatment of organ hypoperfusion and hypoxia are of utmost importance. The major goal is to increase oxygen delivery as soon as possible."

Vascular surgeons are most likely to encounter MODS in cases of extensive blunt trauma, aortic transection/dissection, crush injury, severe ischemia following acute aortic occlusion, mesenteric infarction, and thoracoabdominal aortic surgery, both with extensive direct repair and with hybrid repair. The "hypoxia cascade" can occur without progression to the full multiple organ dysfunction syndrome. "The cascade can occur in refractory hypotension following repair of ruptured aortic aneurysm or other major vascular procedure, during brain ischemia, visceral ischemia, delayed onset paraplegia following repair of thoracoabdominal aortic aneurysms, and during the compartment syndrome."

Recommendations for intraoperative management of thoracoabdominal aortic aneurysms include maintaining visceral perfusion with a pump or a bypass or using visceral perfusion catheters, and perioperative CSF drainage "to allow reduction in the pressure around the spinal cord," he said.

Dr. Hollier said that management of serious injury in the commercial diver in the field has afforded two observations. First, high-dose hyperbaric oxygen, used very early in acute resuscitation of the severely injured, "effectively reduces oxygen debt." Second, the quick reduction of the oxygen debt by high-dose hyperbaric oxygen leverages chances of recovery. "What we do know is that there is only one variable that consistently predicts both mortality and multiple organ dysfunction syndrome following traumatic shock. That is oxygen debt."

Dr. Hollier had no disclosures.

[email protected]

SAN FRANCISCO – Multiple organ dysfunction syndrome is "underappreciated" by many of today’s clinicians, as optimal ways to treat it remain elusive, said Dr. Larry H. Hollier.

At the Vascular Annual Meeting, Dr. Hollier, professor of surgery and chancellor of the Louisiana State University Health Sciences Center, New Orleans, defined multiple organ dysfunction syndrome (MODS) as altered organ functions in an acutely ill patient requiring intervention to achieve homeostasis. "That’s a pretty broad definition, but it’s one of the most common causes of death in surgical intensive care units," he said. "Numerous precipitating factors classically described in multiple organ dysfunction syndrome include sepsis, trauma, cardiac arrest, visceral ischemia, burns, pancreatitis, shock, and major surgery with postoperative instability."

IMNG Medical Media/Martin Allred

The pathophysiology of MODS "is fairly straightforward," he continued. "Some events result in ischemia and tissue hypoxia. Reperfusion occurs with the activation of cytokines, and an exaggerated inflammatory response generates oxygen free radicals, tissue damage, and then organ dysfunction." said Dr. Hollier, the invited speaker for the John Homans Lectureship of the SVS.

The major underlying issue in MODS stems from uncorrected oxygen debt in tissues. In fact, the level of perioperative tissue debt has a direct relationship on postoperative morbidity and mortality. According to Dr. Hollier, the predicted outcome by acutely accumulated oxygen debt in the first 4 hours post injury works like this: 8 L/m² leads to a severe flulike syndrome (mild SIRS); 26 L/m² leads to multiple organ dysfunction syndrome; and 33 L/m² or more leads to death. "The uncorrected oxygen debt in tissues that is initiated is not the end of it," he said. "There’s an accumulating oxygen debt that amasses to keep biomass viable during low oxygen delivery. After resuscitation, there’s increased oxygen required above the basal rate, because explosive oxygen needs occur in order to fuel the inflammation of reperfusion injury."

Conventional therapies for MODS include volume resuscitation, ionotropic agents to improve cardiac performance and increase oxygen delivery, and ventilator support to improve oxygen input. Multiple experimental therapies have also been used, but no universal treatment has been found that reverses MODS, he said. "Early diagnosis and prompt treatment of organ hypoperfusion and hypoxia are of utmost importance. The major goal is to increase oxygen delivery as soon as possible."

Vascular surgeons are most likely to encounter MODS in cases of extensive blunt trauma, aortic transection/dissection, crush injury, severe ischemia following acute aortic occlusion, mesenteric infarction, and thoracoabdominal aortic surgery, both with extensive direct repair and with hybrid repair. The "hypoxia cascade" can occur without progression to the full multiple organ dysfunction syndrome. "The cascade can occur in refractory hypotension following repair of ruptured aortic aneurysm or other major vascular procedure, during brain ischemia, visceral ischemia, delayed onset paraplegia following repair of thoracoabdominal aortic aneurysms, and during the compartment syndrome."

Recommendations for intraoperative management of thoracoabdominal aortic aneurysms include maintaining visceral perfusion with a pump or a bypass or using visceral perfusion catheters, and perioperative CSF drainage "to allow reduction in the pressure around the spinal cord," he said.

Dr. Hollier said that management of serious injury in the commercial diver in the field has afforded two observations. First, high-dose hyperbaric oxygen, used very early in acute resuscitation of the severely injured, "effectively reduces oxygen debt." Second, the quick reduction of the oxygen debt by high-dose hyperbaric oxygen leverages chances of recovery. "What we do know is that there is only one variable that consistently predicts both mortality and multiple organ dysfunction syndrome following traumatic shock. That is oxygen debt."

Dr. Hollier had no disclosures.

[email protected]

SAN FRANCISCO – Multiple organ dysfunction syndrome is "underappreciated" by many of today’s clinicians, as optimal ways to treat it remain elusive, said Dr. Larry H. Hollier.

At the Vascular Annual Meeting, Dr. Hollier, professor of surgery and chancellor of the Louisiana State University Health Sciences Center, New Orleans, defined multiple organ dysfunction syndrome (MODS) as altered organ functions in an acutely ill patient requiring intervention to achieve homeostasis. "That’s a pretty broad definition, but it’s one of the most common causes of death in surgical intensive care units," he said. "Numerous precipitating factors classically described in multiple organ dysfunction syndrome include sepsis, trauma, cardiac arrest, visceral ischemia, burns, pancreatitis, shock, and major surgery with postoperative instability."

IMNG Medical Media/Martin Allred

The pathophysiology of MODS "is fairly straightforward," he continued. "Some events result in ischemia and tissue hypoxia. Reperfusion occurs with the activation of cytokines, and an exaggerated inflammatory response generates oxygen free radicals, tissue damage, and then organ dysfunction." said Dr. Hollier, the invited speaker for the John Homans Lectureship of the SVS.

The major underlying issue in MODS stems from uncorrected oxygen debt in tissues. In fact, the level of perioperative tissue debt has a direct relationship on postoperative morbidity and mortality. According to Dr. Hollier, the predicted outcome by acutely accumulated oxygen debt in the first 4 hours post injury works like this: 8 L/m² leads to a severe flulike syndrome (mild SIRS); 26 L/m² leads to multiple organ dysfunction syndrome; and 33 L/m² or more leads to death. "The uncorrected oxygen debt in tissues that is initiated is not the end of it," he said. "There’s an accumulating oxygen debt that amasses to keep biomass viable during low oxygen delivery. After resuscitation, there’s increased oxygen required above the basal rate, because explosive oxygen needs occur in order to fuel the inflammation of reperfusion injury."

Conventional therapies for MODS include volume resuscitation, ionotropic agents to improve cardiac performance and increase oxygen delivery, and ventilator support to improve oxygen input. Multiple experimental therapies have also been used, but no universal treatment has been found that reverses MODS, he said. "Early diagnosis and prompt treatment of organ hypoperfusion and hypoxia are of utmost importance. The major goal is to increase oxygen delivery as soon as possible."

Vascular surgeons are most likely to encounter MODS in cases of extensive blunt trauma, aortic transection/dissection, crush injury, severe ischemia following acute aortic occlusion, mesenteric infarction, and thoracoabdominal aortic surgery, both with extensive direct repair and with hybrid repair. The "hypoxia cascade" can occur without progression to the full multiple organ dysfunction syndrome. "The cascade can occur in refractory hypotension following repair of ruptured aortic aneurysm or other major vascular procedure, during brain ischemia, visceral ischemia, delayed onset paraplegia following repair of thoracoabdominal aortic aneurysms, and during the compartment syndrome."

Recommendations for intraoperative management of thoracoabdominal aortic aneurysms include maintaining visceral perfusion with a pump or a bypass or using visceral perfusion catheters, and perioperative CSF drainage "to allow reduction in the pressure around the spinal cord," he said.

Dr. Hollier said that management of serious injury in the commercial diver in the field has afforded two observations. First, high-dose hyperbaric oxygen, used very early in acute resuscitation of the severely injured, "effectively reduces oxygen debt." Second, the quick reduction of the oxygen debt by high-dose hyperbaric oxygen leverages chances of recovery. "What we do know is that there is only one variable that consistently predicts both mortality and multiple organ dysfunction syndrome following traumatic shock. That is oxygen debt."

Dr. Hollier had no disclosures.

[email protected]