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Publications (20)

  • Gaurav Sharma · Ming Tao · Kui Ding · [...] · Marcus E Semel
    [Show abstract] [Hide abstract] ABSTRACT: Recent symptoms stand as a major determinant of stroke risk in patients with carotid stenosis, likely reflective of atherosclerotic plaque destabilization. In view of emerging links between vascular and adipose biology, we hypothesized that human perivascular adipose characteristics associate with carotid disease symptom status. Clinical history, carotid plaques, blood, and subcutaneous and perivascular adipose tissues were prospectively collected from patients undergoing carotid endarterectomy. Nine adipose-associated biological mediators were assayed and compared in patients with symptomatic (n=15) versus asymptomatic (n=19) disease. Bonferroni correction was performed for multiple testing (α/9=0.006). Symptomatic patients had 1.9-fold higher perivascular adiponectin levels (P=0.005). Other circulating, subcutaneous, and perivascular biomarkers, as well as microscopic plaque characteristics, did not differ between symptomatic and asymptomatic patients. Symptomatic and asymptomatic carotid endarterectomy patients display a tissue-specific difference in perivascular adipose adiponectin. This difference, which was not seen in plasma or subcutaneous compartments, supports a potential local paracrine relationship with vascular disease processes that may be related to stroke mechanisms. © 2015 American Heart Association, Inc.
    Article · May 2015 · Stroke
  • Neal R Barshes · Edwin C Gravereaux · Marcus Semel · [...] · Michael Belkin
    [Show abstract] [Hide abstract] ABSTRACT: The thickened intimal flap present in cases of chronic aortic dissection can present a challenge to attempts at endovascular stent graft treatment performed for subsequent aneurysmal degeneration by precluding adequate landing zones for the endograft and by constraining the endograft from full expansion. In this report we describe our technique and outcome for longitudinal endovascular fenestration of chronic aortic dissection flaps to facilitate endovascular stent graft treatment for thoracic aortic aneurysms developing after aortic dissection. Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
    Article · Mar 2015 · Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
  • M.E. Semel · L. Hsu · C.K. Ozaki
    Chapter · Feb 2015
  • D. Yu · M. Tao · A. Longchamp · [...] · C. K. Ozaki
    Article · Jan 2015 · Journal of Investigative Medicine
  • [Show abstract] [Hide abstract] ABSTRACT: Objective Surgical treatment of acute axillosubclavian vein thrombosis from venous thoracic outlet syndrome (VTOS) traditionally involves first rib resection and scalenectomy (FRRS) followed by interval venography and balloon angioplasty. This approach can lead to an extended need for anticoagulation and a separate anesthesia session. We present outcomes for FRRS with concurrent venography. Methods Retrospective chart review was performed for consecutive patients undergoing FRRS with concurrent venography for VTOS from February 2007 to April 2014. Venography was performed immediately after FRRS with the arm in neutral and provocative positions. The primary outcomes of this study were primary and primary-assisted patency. Secondary outcomes included whether concurrent venography resulted in modification of the procedure, postoperative anticoagulation use, and postoperative complications. Results Thirty patients underwent first rib resection with venography with a mean follow-up time of 24.4 months. The mean age was 29.5 years (range, 17-52 years), and 17 (56.7%) were female. All were maintained on anticoagulation before the procedure. Concurrent venography resulted in modification of the procedure in 28 patients (93.3%). Of these, 27 patients (96.4%) underwent balloon angioplasty and two patients (7.1%) underwent further rib resection. Twenty patients (66.7%) were discharged after the procedure with no anticoagulation. For those receiving postoperative anticoagulation for persistent minor thrombus, median time for anticoagulation duration was 5.0 months (range, 0.8 and 16.7 months). Two patients (6.7%) had postoperative bleeding requiring thoracentesis or video-assisted thoracoscopic evacuation of hemothorax. One patient (3.3%) suffered rethrombosis and was successfully lysed open, resulting in a 2-year subclavian vein (SCV) primary patency of 96.7% and primary-assisted patency of 100%. No patients required reoperation for VTOS, and all reported improvements in symptoms. Three patients (10.0%) later underwent prophylactic first rib resection on the contralateral side for symptoms and SCV stenosis. Conclusions FRRS with concurrent venography is a safe procedure for VTOS that allows effective intraoperative modification of the surgical plan, resulting in excellent patency of the SCV, early cessation of anticoagulation, and durable relief of symptoms. Copyright © 2015 Published by Elsevier Inc. on behalf of the Society for Vascular Surgery.
    Article · Dec 2014
  • Gaurav Sharma · Marcus E. Semel · Edward A. McGillicuddy · [...] · Jonathan D. Gates
    [Show abstract] [Hide abstract] ABSTRACT: Aneurysms of the superior mesenteric artery (SMA) and branches thereof are uncommon, but have a high rate of rupture and mortality relative to other visceral artery aneurysms. Historically, the predominant etiology has been infectious; with a renewed rise in intravenous drug abuse (IVDA) rates in the last decade, we hypothesize a resurgence in septic embolic complications may occur in the coming years. Here we describe the presentation and management of two cases of intravenous drug users presenting with infectious endocarditis and SMA main trunk and branch aneurysms, one of which was ruptured. In addition, we review the literature on these rare clinical entities.
    Article · Nov 2014 · Annals of Vascular Surgery
  • [Show abstract] [Hide abstract] ABSTRACT: Objective To assess in-hospital mortality in patients undergoing many commonly performed urological surgeries in light of decreasing nationwide perioperative mortality over the past decade. This phenomenon has been attributed in part to a decline in ‘failure to rescue’ (FTR) rates, e.g. death after a complication that was potentially recognisable/preventable.Patients and Methods Discharges of all patients undergoing urological surgery between 1998 and 2010 were extracted from the Nationwide Inpatient Sample and assessed for overall and FTR mortality. Admission trends were assessed with linear regression. Logistic regression models fitted with generalised estimating equations were used to estimate the impact of primary predictors on over-all and FTR mortality and changes in mortality rates.ResultsBetween 1998 and 2010, an estimated 7 725 736 urological surgeries requiring hospitalisation were performed in the USA; admissions for urological surgery decreased 0.63% per year (P = 0.008). Odds of overall mortality decreased slightly (odds ratio [OR] 0.990, 95% confidence interval [CI] 0.988-0.993), yet the odds of mortality attributable to FTR increased 5% every year (OR 1.050, 95% CI 1.038-1.062). Patient age, race, Charlson Comorbidity Index, public insurance status, as well as urban hospital location were independent predictors of FTR mortality (P < 0.001).ConclusionA shift from inpatient to outpatient surgery for commonly performed urological procedures has coincided with increasing rates of FTR mortality. Older, sicker, minority group patients and those with public insurance were more likely to die after a potentially recognisable/preventable complication. These strata of high-risk individuals represent ideal targets for process improvement initiatives.
    Article · Jun 2014 · BJU International
  • Marcus E. Semel · Thomas T. Tsai · Edward A. McGillicuddy · [...] · Michael Belkin
    Article · Jun 2014 · Journal of Vascular Surgery
  • Karen J Ho · Arin L Madenci · Marcus E Semel · [...] · Michael Belkin
    [Show abstract] [Hide abstract] ABSTRACT: In the United States, vascular surgeons frequently perform carotid endarterectomy (CEA). Given the resource burden of unplanned readmission (URA), we sought to identify the predictors and consequences of URA after this common vascular surgery procedure to identify potential points of intervention. Using a prospective single-institution database, we retrospectively identified consecutive patients undergoing CEA (2001-2011). Demographic and perioperative factors were prospectively collected. The primary end point was 30-day postdischarge URA after CEA. The secondary end point was 1-year survival. We performed a univariable analysis for URA followed by a multivariable Cox model. A Kaplan-Meier analysis was performed for 1-year survival. During the study period, 840 patients underwent 897 CEAs. The 30-day postdischarge overall readmission rate and URA rate were 8.6% and 6.5%, respectively. Most URA patients (n = 42; 73.4%) were readmitted for a CEA-related reason (headache, cardiac, hypertension, surgical site infection, bleeding/hematoma, stroke/transient ischemic attack, dysphagia, or hyperperfusion syndrome). Seventeen patients (29.3%) had more than one reason for URA. Median time to URA was 4 days (interquartile range, 1-9 days). Postoperative length of stay, indication for CEA, and discharge destination were not associated with URA. In multivariable analysis, in-hospital occurrence of congestive heart failure (hazard ratio [HR], 15.1; 95% confidence interval [CI], 4.7-48.8; P < .001), stroke (HR, 5.0; 95% CI, 1.8-14.0; P < .001), bleeding/hematoma (HR, 3.1; 95% CI, 1.4-6.9; P = .003), and prior coronary artery bypass grafting (HR, 2.0; 95% CI, 1.2-3.5; P = .01) were significantly associated with URA. Patients in the URA group also had decreased survival during 1 year (91% vs 96%; P = .01, log-rank). The 30-day URA rate after CEA is low (6.5%). Prior coronary artery bypass grafting and in-hospital postoperative occurrence of stroke, bleeding/hematoma, and congestive heart failure identify those at increased risk of URA, and URA signals increased long-term risk of postoperative mortality.
    Article · Mar 2014 · Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
  • [Show abstract] [Hide abstract] ABSTRACT: Hospital length of stay (LOS) contributes to costs. Carotid endarterectomy (CEA) is performed frequently by vascular surgeons, making contemporary CEA LOS rates and predictors vital knowledge for quality evaluation and cost containment initiatives. Using a prospective single-institution database, we retrospectively identified consecutive patients undergoing CEA from 2001 to 2011. Demographic and perioperative factors were prospectively collected. The primary end point was extended postoperative LOS (ELOS), defined as postoperative LOS ≥2 days. Factors associated with ELOS were analyzed in a multivariable logistic regression model. Rates of 1-year readmission and death were compared with the Kaplan-Meier method (log-rank test). Eight hundred forty patients underwent 897 CEAs with 39% of procedures among females and 35% for symptomatic disease. One hundred two (11.4%) patients were inpatients prior to the day of CEA ("preadmitted"); their preoperative days by definition are not included in ELOS. Median postoperative LOS was 1 day (interquartile range, 1-2). Four hundred fourteen patients (46.2%) had ELOS. Preadmission was associated with ELOS (72% vs 41%; P < .01) and ELOS patients were less likely to be discharged home (11.9% vs 1.5%; P < .01). There was no association between ELOS and unplanned 30-day postdischarge readmission (6.0% vs 7.0%; P = .59). On multivariable analysis, preoperative factors significantly associated with ELOS included preadmission (adjusted odds ratio [OR], 3.3; 95% confidence interval [CI], 1.9-5.7; P < .001), history of congestive heart failure (OR, 2.1; 95% CI, 1.1-4.2; P = .03), female gender (OR, 1.9; 95% CI, 1.4-2.6; P < .001), and history of chronic obstructive pulmonary disease (OR, 1.7; 95% CI, 1.0-2.9; P = .04). Operative factors included electroencephalography change (OR, 1.9; 95% CI, 1.2-3.2; P = .01), operating room start time after 12:00 pm (OR, 1.7; 95% CI, 1.2-2.4; P < .01), and total operating room time (OR, 1.5 per hour; 95% CI, 1.2-2.9; P < .01). Postoperative factors included transfer to intensive care unit (OR, 5.4; 95% CI, 3.1-9.4; P < .01), number of in-hospital postoperative complications (OR, 3.7; 95% CI, 2.2-6.5; P < .01), and Foley catheter placement (OR, 2.1; 95% CI, 1.3-3.4; P < .01). Over 1 year, ELOS was associated with increased hospital readmission (93.6% vs 84.7%; log-rank test, P < .01) and decreased survival (95.1% vs 98.3%; log-rank test, P < .01). Nearly half of CEA patients were discharged on or after postoperative day 2. Interventions on modifiable risk factors, such as early Foley catheter placement to prevent urinary retention and morning CEA scheduling, may decrease LOS. ELOS may identify a subset of patients at increased risk for long-term readmission and mortality.
    Article · Jan 2014 · Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter
  • Marcus E. Semel · Karen J. Ho · C. Keith Ozaki · Michael Belkin
    Article · Sep 2013 · Journal of Vascular Surgery
  • Article · Sep 2013 · Journal of Vascular Surgery
  • [Show abstract] [Hide abstract] ABSTRACT: Rationale, aims and objectives At present, the range of services delivered in a health system is not known. Currently there are no accepted methods for defining the scope of ambulatory care. Therefore we used data from the electronic medical record and billing system of a large non-profit multi-specialty group practice to measure the number of different diagnoses that clinicians managed as well as the number of different medications, laboratory tests, imaging studies, referrals and procedures ordered. Methods All patient encounters and clinicians in the group practice in 2008 were eligible for inclusion in the analysis. Data were analysed cumulatively for the practice and by specialty. Quantile regression models were used to adjust for differences in full-time equivalents (FTE) among physicians at the practice. Results In one year for this practice, with 324 229 patients who made 3 193 917 office visits to 578 physicians and 248 other clinicians, patients presented with 5638 primary and 6411 secondary diagnoses. Overall, patient management resulted in unique orders for 9481 medications, 1182 laboratory tests, 613 referrals, 284 imaging studies and 1701 procedures. After adjusting for FTE, physicians managed a median of 249 primary diagnoses and 347 secondary diagnoses. They ordered a median of 278 medications, 128 laboratory tests, 51 referrals, 29 imaging studies and 39 procedures. Conclusion Physicians routinely manage a substantial variety of diagnoses, medications, and other tests and procedures. Quality improvement and health services researchers have generally focused on individual services but also must consider the wide variety and range of services delivered.
    Article · Apr 2012 · Journal of Evaluation in Clinical Practice
  • Marcus E Semel · Stuart R Lipsitz · Luke M Funk · [...] · Atul A Gawande
    [Show abstract] [Hide abstract] ABSTRACT: Nationwide rates and patterns of death after surgery are unknown. Using the Nationwide Inpatient Sample, we compared deaths within 30 days of admission for patients undergoing surgery in 1996 and 2006. International Classification of Diseases codes were used to identify 2,520 procedures for analysis. We examined the inpatient 30-day death rate for all procedures, procedures with the most deaths, high-risk cardiovascular and cancer procedures, and patients who suffered a recorded complication. We used logistic regression modeling to adjust 1996 mortality rates to the age and gender distributions for patients undergoing surgery in 2006. In 1996, there were 12,573,331 admissions with a surgical procedure (95% confidence interval [CI], 12,560,171-12,586,491) and 224,111 inpatient deaths within 30 days of admission (95% CI, 221,912-226,310). In 2006, there were 14,333,993 admissions with a surgical procedure (95% CI, 14,320,983-14,347,002) and 189,690 deaths (95% CI, 187,802-191,578). Inpatient 30-day mortality declined from 1.68% in 1996 to 1.32% in 2006 (P < .001). Of the 21 procedures with the most deaths in 1996, 15 had significant declines in adjusted mortality in 2006. Among these 15 procedures, 8 had significant declines in operative volume. The inpatient 30-day mortality rate for patients who suffered a complication decreased from 12.10% to 9.84% (P < .001). Nationwide reporting on surgical mortality suggests that the number of inpatient deaths within 30 days of surgery has declined. Additional research to determine the underlying causes for decreased mortality is warranted.
    Article · Feb 2012 · Surgery
  • Alvin C Kwok · Marcus E Semel · Stuart R Lipsitz · [...] · Ashish K Jha
    [Show abstract] [Hide abstract] ABSTRACT: Although the extent of hospital and intensive-care use at the end of life is well known, patterns of surgical care during this period are poorly understood. We examined national patterns of surgical care in the USA among elderly fee-for-service Medicare beneficiaries in their last year of life. We did a retrospective cohort study of elderly beneficiaries of fee-for-service Medicare in the USA, aged 65 years or older, who died in 2008. We identified claims for inpatient surgical procedures in the year before death and examined the relation between receipt of an inpatient procedure and both age and geographical region. We calculated an end-of-life surgical intensity (EOLSI) score for each hospital referral region defined as proportion of decedents who underwent a surgical procedure during the year before their death, adjusted for age, sex, race, and income. We compared patient characteristics with Rao-Scott χ(2) tests, resource use with generalised estimating equations, regional differences with generalised estimating equations Wald tests, and end-of-life surgical intensity scores with Spearman's partial-rank-order correlation coefficients. Of 1,802,029 elderly beneficiaries of fee-for-service Medicare who died in 2008, 31·9% (95% CI 31·9-32·0; 575,596 of 1,802,029) underwent an inpatient surgical procedure during the year before death, 18·3% (18·2-18·4; 329,771 of 1,802,029) underwent a procedure in their last month of life, and 8·0% (8·0-8·1; 144,162 of 1,802,029) underwent a procedure during their last week of life. Between the ages of 80 and 90 years, the percentage of decedents undergoing a surgical procedure in the last year of life decreased by 33% (35·3% [95% CI 34·7-35·9; 8858 of 25,094] to 23·6% [22·9-24·3; 3340 of 14,152]). EOLSI score in the highest intensity region (Munster, IN) was 34·4 (95% CI 33·7-35·1) and in the lowest intensity region (Honolulu, HI) was 11·5 (11·3-11·7). Regions with a high number of hospital beds per head had high end-of-life surgical intensity (r=0·37, 95% CI 0·27-0·46; p<0·0001), as did regions with high total Medicare spending (r=0·50, 0·41-0·58; p<0·0001). Many elderly people in the USA undergo surgery in the year before their death. The rate at which they undergo surgery varies substantially with age and region and might suggest discretion in health-care providers' decisions to intervene surgically at the end of life. None.
    Article · Oct 2011 · The Lancet
  • Thomas G Weiser · Marcus E Semel · Alan E Simon · [...] · Atul A Gawande
    [Show abstract] [Hide abstract] ABSTRACT: Over the past decade, improvements in perioperative care have been widely introduced throughout the United States, yet there is no clear indication that the death rate following surgery has improved. We sought to evaluate the number of deaths after surgery in the United States over a 10-year period and to evaluate trends in postoperative mortality. Using the National Hospital Discharge Survey, we identified patients who underwent a surgical procedure and subsequently died in the hospital within 30 days of admission. In 1996 there were 12,250,000 hospitalizations involving surgery, rising to 13,668,000 in 2006. Postoperative deaths, however, declined during this same period, from 201,000 to 156,000 (P < 0.01), giving a postoperative in-hospital death ratio (death per hospitalization) of 1.64 and 1.14% (P < 0.001), respectively, for the two time frames. The death rate following surgery is substantial but appears to have improved. Such mortality statistics provide an essential measure of the public health impact of surgical care. Incorporating mortality statistics following therapeutic intervention is an essential strategy for regional and national surveillance of care delivery.
    Article · Sep 2011 · World Journal of Surgery
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    Luke M Funk · Atul A Gawande · Marcus E Semel · [...] · Ashish K Jha
    [Show abstract] [Hide abstract] ABSTRACT: To evaluate the association between systems characteristics and esophagectomy mortality at low-volume hospitals High-volume hospitals have lower esophagectomy mortality rates, but receiving care at such centers is not always feasible. We examined low-volume hospitals and sought to identify characteristics of those with better outcomes. Using national data from Medicare and the American Hospital Association, we studied 4498 elderly patients who underwent an esophagectomy from 2004 to 2007. We divided hospitals into terciles based on esophagectomy volume and examined characteristics of patients and hospitals (size, nurse ratios, and presence of advanced medical, surgical, and radiological services). Our primary outcome was mortality. We identified 5 potentially beneficial systems characteristics in our data set and used multivariable logistic regression to determine whether these characteristics were associated with lower mortality rates at low-volume hospitals. Of the 874 hospitals that performed esophagectomies, 83% (723) were low-volume hospitals whereas only 3% (25) were high-volume. Low-volume hospitals performed a median of 1 esophagectomy during the 4-year study period and cared for patients that were older, more likely to be minority, and more likely to have multiple comorbidities compared with high-volume centers. Low-volume hospitals that had at least 3 of 5 characteristics (high nurse ratios, lung transplantation services, complex medical oncology services, bariatric surgery services, and positron emission tomography scanners) had markedly lower mortality rates compared with low-volume hospitals with none of these characteristics (12.5% vs. 5.0%; P value = 0.042). Low-volume hospitals with certain systems characteristics seem to achieve better esophagectomy outcomes. A more comprehensive study of the beneficial characteristics of low-volume hospitals is warranted because high-volume hospitals are difficult to access for many patients.
    Full-text available · Article · Mar 2011 · Annals of surgery
  • Marcus E. Semel · Angela Bader · Atul A. Gawande
    Article · Dec 2010 · Health Affairs
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    Marcus E Semel · Stephen Resch · Alex B Haynes · [...] · Atul A Gawande
    [Show abstract] [Hide abstract] ABSTRACT: Use of the World Health Organization's Surgical Safety Checklist has been associated with a significant reduction in major postoperative complications after inpatient surgery. We hypothesized that implementing the checklist in the United States would generate cost savings for hospitals. We performed a decision analysis comparing implementation of the checklist to existing practice in U.S. hospitals. In a hospital with a baseline major complication rate after surgery of at least 3 percent, the checklist generates cost savings once it prevents at least five major complications. Using the checklist would both save money and improve the quality of care in hospitals throughout the United States.
    Full-text available · Article · Sep 2010 · Health Affairs
  • Marcus E Semel · Ali Tavakkolizadeh · Jonathan D Gates
    [Show abstract] [Hide abstract] ABSTRACT: In an immunocompetent host, Babesia microti has not been reported as a cause of postoperative fever. Case report and literature review. A 52-year-old woman living on Martha's Vineyard developed postoperative fever after splenectomy for trauma. The patient's mechanism of injury was a fall from a stationary bicycle. Intraoperatively, the patient was noted to have splenomegaly. Postoperatively, she developed fever and was found to have Babesia microti on blood smear with an otherwise negative fever evaluation. She was treated with atovaquone and azithromycin and made a full recovery. For individuals who have lived or traveled in endemic areas, babesiosis should be considered as a possible cause of postoperative fever when other sources have been excluded. Patients undergoing splenectomy in an endemic area should be screened for babesiosis to prevent postoperative recrudescence of symptoms.
    Article · Aug 2009 · Surgical Infections