Obstetric Anesthesia Liability Concerns.

Obstetric practice carries a high risk of medical liability and involves both obstetricians and anesthesiologists. Analysis of data from the Anesthesia Closed Claims Project database shows an increase in the proportion of anesthesia claims for maternal death and brain damage between the 1990s and 2000 and later, primarily due to hemorrhage. The proportion of claims for newborn brain damage remained unchanged while those for maternal nerve injury and minor injuries decreased. Use of massive transfusion protocols and clinical drills have been shown to improve outcomes from hemorrhage. Good communication and teamwork are critical for reducing obstetric liability.

Cost of detecting a chronic solvent encephalopathy case by screening.

BACKGROUND: Stepwise screening of chronic solvent encephalopathy (CSE), using a postal survey followed by clinical examinations, has been shown to detect symptomatic exposed workers with an occupational disease even in industrialized countries with long-term, but relatively low dose exposure. Previous studies have suggested under-detection and late recognition of CSE, when work ability is already markedly reduced. AIMS: The aim was to estimate the cost of detecting one new CSE case by screening and diagnostics, to estimate the career extension needed to cover the cost of screening, and to study the work ability of the CSE cases. METHODS: A financial analysis of stepwise postal CSE screening followed by clinical examinations (SPC screening) was carried out, and the results were compared to those of the group of CSE cases referred to the Finnish Institute of Occupational Health (FIOH) by the existing national practice of occupational health services (OHS screening). The work ability of the SPC screened CSE cases was studied in relation to the retirement rate and the Work Ability Index (WAI). RESULTS: An analysis of the costs of detecting a new verified CSE case revealed them to be approximately 16,500 USD. Using the mean monthly wages in the fields concerned, we showed that if a worker is able to continue working for four months longer, the screening covers these costs. The cost for detecting a CSE case was twenty times higher with the existing OHS routine, when actualized according to the national guidelines. A CSE case detected at an early stage enables occupational rehabilitation or measures to decrease solvent exposure. The retirement rate of the SPC screened CSE cases was significantly lower than that of the OHS screened cases (6.7% vs. 74%). The results suggest that SPC screening detects patients at an earlier stage of the disease, when they are still capable of working. Their WAI sores were nevertheless lower than those of the general population, implying a greater risk of becoming excluded from the labor market. CONCLUSION: Stepwise screening of CSE using a postal survey followed by clinical examinations detected new CSE cases at lower costs than existing OHS screening routines. Detecting CSE at an early stage prevents early retirement.

Trends in anesthesia-related death and brain damage: A closed claims analysis.

BACKGROUND: The authors used the American Society of Anesthesiologists Closed Claims Project database to determine changes in the proportion of claims for death or permanent brain damage over a 26-yr period and to identify factors associated with the observed changes. METHODS: The Closed Claims Project is a structured evaluation of adverse outcomes from 6,894 closed anesthesia malpractice claims. Trends in the proportion of claims for death or permanent brain damage between 1975 and 2000 were analyzed. RESULTS: Claims for death or brain damage decreased between 1975 and 2000 (odds ratio, 0.95 per year; 95% confidence interval, 0.94-0.96; P < 0.01). The overall downward trend did not seem to be affected by the use of pulse oximetry and end-tidal carbon dioxide monitoring, which began in 1986. The use of these monitors increased from 6% in 1985 to 70% in 1989, and thereafter varied from 63% to 83% through the year 2000. During 1986-2000, respiratory damaging events decreased while cardiovascular damaging events increased, so that by 1992, respiratory and cardiovascular damaging events occurred in approximately the same proportion (28%), a trend that continued through 2000. CONCLUSION: The significant decrease in the proportion of claims for death or permanent brain damage from 1975 through 2000 seems to be unrelated to a marked increase in the proportion of claims where pulse oximetry and end-tidal carbon dioxide monitoring were used. After the introduction and use of these monitors, there was a significant reduction in the proportion of respiratory and an increase in the proportion of cardiovascular damaging events responsible for death or permanent brain damage.

Injuries associated with regional anesthesia in the 1980s and 1990s: a closed claims analysis.

BACKGROUND: The authors used the American Society of Anesthesiologists Closed Claims Project database to identify specific patterns of injury and legal liability associated with regional anesthesia. Because obstetrics represents a unique subset of patients, claims with neuraxial blockade were divided into obstetric and nonobstetric groups for comparison. METHODS: The American Society of Anesthesiologists Closed Claims Project is a structured evaluation of adverse anesthetic outcomes collected from closed anesthesia malpractice insurance claims of professional liability companies. An in-depth analysis of 1980-1999 regional anesthesia claims was performed with a subset comparison between obstetric and nonobstetric neuraxial anesthesia claims. RESULTS: Of the total 1,005 regional anesthesia claims, neuraxial blockade was used in 368 obstetric claims and 453 of 637 nonobstetric claims (71%). Damaging events in 51% of obstetric and 41% of nonobstetric neuraxial anesthesia claims were block related. Obstetrics had a higher proportion of neuraxial anesthesia claims with temporary and low-severity injuries (71%) compared with the nonobstetric group (38%; P

A comparison of neuropsychological tests for the assessment of chronic toxic encephalopathy.

BACKGROUND: From the viewpoint of the clinical neuropsychologist, it is not evident if the detection of solvent induced toxic encephalopathy (TE) could be optimized by a modification of the traditional test batteries, adding tests covering new dimensions or monitoring further functional domains. METHODS: To clarify this issue, TE patients were re-examined with (a) the tests traditionally used in screening for TE and (b) some tests hitherto less utilized within neurotoxicology, involving complex attention and frontal lobe functioning. RESULTS: The results do not indicate that tests of the latter category would be more sensitive to TE than the tests traditionally used. Using an optimized core battery, compiled of tests from both categories, the sensitivity and specificity levels reached a maximum of around 0.7 when using as criterion the reproduction of a subnormal test profile (TE type 2B). CONCLUSIONS: A combination of several traditional and a few newer tests is suggested to optimize the detection of TE. Repeated assessments over time are also recommended.

[Late effects of occupational organic brain damage in painters 6-8 years after diagnosis. Occurrence of mental and psychosomatic health problems and utilization of health services]. / Senvirkninger af erhvervsbetinget organisk hjerneskade hos malere 6-8 år efter diagnosetidspunktet. Forekomst af psykiske og psykosomatiske helbredsproblemer samt forbrug af sundhedsydelser.

With the object of illustrating effects on health and social functions of occupational organic brain damage, a questionnaire study was carried out in 1986 concerning 192 brain-damaged painters and a reference group of 341 other painters. The study was repeated in 1990 to elucidate effects six to eight years after diagnosis. In 1986 a high prevalence of mental and psychosomatic symptoms was found among the brain-damaged painters. The prevalence correlated with severity of the disease, occupational situation and social network. In 1990 the same level of symptoms was found. In the reference group the prevalence of symptoms increased from 1986 to 1990. Besides the major difference in the prevalence of symptoms between the two groups, the level of symptoms correlated to the occupational situation in both groups. Twenty-seven percent of the brain-damaged painters were still at work in 1990. The high symptom level among the brain-damaged painters is considered to be chronic.

Neuropsychological toxicology of methylene diphenyl diisocyanate: a report of five cases.

The neuropsychological functioning of five men suffering alleged physical, cognitive and behavioural changes following exposure to methylene diphenyl diisocyanate (MDI), an industrial chemical, was investigated in the present study. At the time of assessment, four of the five patients remained symptomatic despite having no contact with MDI for periods ranging from 5 to 9 months. All patients reported experiencing subjective symptoms consisting of respiratory distress, headaches, depression, irritability, forgetfulness, decreased calculating ability, word-finding problems and reduced concentration. While the pattern of neuropsychological deficits varied among the patients, common findings for the group included intact psychomotor, psychosensory, visuographic and language functions accompanied by deceased concentration, mental efficiency, rate of information processing, learning ability and abstract reasoning. All five patients also revealed significant emotional distress on an objective personality measure. In general, the neuropsychological test data support the presence of behavioural and cognitive correlates of CNS injury following exposure to MDI.

Computerized tomography and neuropsychological assessment in long-term high-dose heroin addicts.

A clinico-radiological assessment of seven high-dose long-term heroin addicts was undertaken to look for the presence of neuropsychological and CT scan pathology. Definite abnormalities were found in both neuropsychological and CT scan assessments in some individuals but the pattern of CT scan and neuropsychological deficit in relation to heroin addiction was not constant.

[Late sequelae after occupational exposure to organic solvents. Exposure assessment in diagnosing chronic toxic encephalopathy]. / Senskader etter yrkeseksponering for organiske løsemidler. Vurdering av eksponeringen i den diagnostiske utredning av kronisk toksisk encefalopati.

Organic solvents are debated as a cause of chronic toxic encephalopathy. The pathogenesis is not completely known. There are some indications of structural changes in the central nervous system. Epidemiological studies are saddled with potential faults and methodological problems, but in total the epidemiological evidence for a causal association between solvents and encephalopathy is sound. The first step in the diagnosis is to demonstrate encephalopathy by neurological and neuropsychological methods. The next step is to estimate the probability of solvents being the cause of this encephalopathy. Misjudgement of diagnosis is often due to uncertainty in the exposure evaluation. We discuss elements of the exposure assessment, and outline neuropsychological testing as part of the diagnostic process.

Behavioral teratology as the study of early brain damage: considerations for the assessment of neonates.

Research in early traumatic brain damage indicates that, because of recovery-of-function, the behavioral effects of teratogenic agents and experiences may be easier to detect in younger animals. This makes early assessment desirable in behavioral teratogenicity screens, but requires careful consideration of the unique capabilities of the neonate and the assessment of behaviors more sophisticated than relatively gross motor behaviors. Several behaviors are discussed as examples of tests appropriate to the early assessment of CNS integrity. These tests may prove valuable as powerful, cost-effective discriminators of teratogenicity.

Childhood vaccine: US plans federal compensation.

KIE: Legislation has been proposed to create a federal compensation fund for children suffering vaccine induced injuries. Pharmaceutical companies and the Administration would prefer that the bill not contain the option to sue the companies. An increasing liability burden has caused some manufacturers to stop making certain vaccines.^ieng