Medical Malpractice and Trigeminal Neuralgia: An Analysis of 49 Cases.

PURPOSE: Our study fills the vacancy of litigation research related to trigeminal neuralgia management, giving health care providers the information needed to understand the potential litigious outcomes that follow treatment methods. METHODS: We queried the Westlaw database to identify litigation cases related to trigeminal neuralgia management. Key variables extracted included medical complaints, trial outcomes, and demographics. Continuous variables were compared between cases in favor of defendant and cases in favor of plaintiff using t-test or Wilcoxon rank sum test. Categorial variables were compared using χ2 or Fisher exact test. RESULTS: About 49 cases met the inclusion criteria-for those cases surgical complications (42.9%) were cited as the most common reasons for malpractice claims. Cranial nerve deficits (34.7%) were the most frequent postoperative complaints. Verdicts ruled in favor of the plaintiff in 26.5% of cases with a mean payout of $1,982,428.46. Dentists were included in the most cases, 63.3%, and the average payout was $415,908, whereas neurosurgeons were involved in 20.4% of cases with an average payout of $618,775. Cases with verdicts in favor of the plaintiff were more likely to be older than cases with verdicts in favor of the defendant (P = .03). CONCLUSIONS: Over one-half of cases resulted in verdicts in favor of the defendant with surgical complications cited as the most common reason for litigation. Dentistry was the most common individual clinical specialty for defendants, whereas neurosurgery contributed to the largest average payout based on specialty (for n > 1). Cranial nerve deficits were the most common plaintiff postoperative complaints. These analyses may help doctor teams involved in management of trigeminal neuralgia to have a more informed discussion with the patient at every visit so that such litigations may be avoided.

Medical malpractice and meningiomas: an analysis of 47 cases.

OBJECTIVE: Among medical practices, surgical fields, including neurosurgery, are at a high risk for medical malpractice litigation. With meningiomas contributing to 10% of the total neurosurgery litigation cases, the aim of this study was to identify demographic characteristics, reasons for litigation, and surgical complications commonly reported in these cases. This analysis serves to increase neurosurgeons' awareness of factors associated with medical malpractice litigation. METHODS: The online legal database Westlaw was utilized to query public litigation cases related to the medical management of meningiomas between December 1985 and May 2020. Variables extracted included the following: plaintiff and defendant demographics, litigation category, plaintiff medical complaints, and trial outcomes. The authors compared these characteristics between cases with decisions in favor of the defendant and those with decisions in favor of the plaintiff. RESULTS: A total of 47 cases met the inclusion criteria. Failure to diagnose (68.1%) was the most common type of malpractice claim, and surgical complications (19.1%), motor weakness (33%), and financial loss (33%) were cited as the most common postoperative complaints. Individual specialties that most often required defense due to malpractice claims were radiology (21.7%) and neurosurgery (19.6%). The jury verdict was in favor of the defense in 51.1% of cases and in favor of the plaintiff in 27.7% of cases. A settlement was reached in 19.1% of cases. The mean payout for a verdict in favor of the plaintiff was $3,409,650.22, while the mean payout for settlements was $867,555.56. The greatest average payout for specialties was in neurosurgery at $3,414,400, followed by radiology at $3,192,960. Cases with a verdict in favor of the plaintiff were more likely to involve an internal medicine physician as a defendant (p = 0.007). CONCLUSIONS: Over one-half of the cases resulted in a defendant's verdict with failure to diagnose cited as the most common reason for litigation. Radiology and neurosurgery were the most common specialties for legal cases and also had some of the largest average payouts based on specialty. Motor weakness and financial loss were the most common plaintiff postoperative complaints. These findings may inform surgeons on active measures to take, such as increasing focus on diagnostic accuracy and reducing specific postoperative complaints, such as motor weakness, through risk management and prophylactic measures, to reduce unfavorable legal outcomes.

An In Vivo Platform for Rebuilding Functional Neocortical Tissue.

Recent progress in cortical stem cell transplantation has demonstrated its potential to repair the brain. However, current transplant models have yet to demonstrate that the circuitry of transplant-derived neurons can encode useful function to the host. This is likely due to missing cell types within the grafts, abnormal proportions of cell types, abnormal cytoarchitecture, and inefficient vascularization. Here, we devised a transplant platform for testing neocortical tissue prototypes. Dissociated mouse embryonic telencephalic cells in a liquid scaffold were transplanted into aspiration-lesioned adult mouse cortices. The donor neuronal precursors differentiated into upper and deep layer neurons that exhibited synaptic puncta, projected outside of the graft to appropriate brain areas, became electrophysiologically active within one month post-transplant, and responded to visual stimuli. Interneurons and oligodendrocytes were present at normal densities in grafts. Grafts became fully vascularized by one week post-transplant and vessels in grafts were perfused with blood. With this paradigm, we could also organize cells into layers. Overall, we have provided proof of a concept for an in vivo platform that can be used for developing and testing neocortical-like tissue prototypes.

Phasic stimulation in the nucleus accumbens enhances learning after traumatic brain injury.

Traumatic brain injury (TBI) is a significant cause of morbidity and mortality worldwide. Despite improvements in survival, treatments that improve functional outcome remain lacking. There is, therefore, a pressing need to develop novel treatments to improve functional recovery. Here, we investigated task-matched deep-brain stimulation of the nucleus accumbens (NAc) to augment reinforcement learning in a rodent model of TBI. We demonstrate that task-matched deep brain stimulation (DBS) of the NAc can enhance learning following TBI. We further demonstrate that animals receiving DBS exhibited greater behavioral improvement and enhanced neural proliferation. Treated animals recovered to an uninjured behavioral baseline and showed retention of improved performance even after stimulation was stopped. These results provide encouraging early evidence for the potential of NAc DBS to improve functional outcomes following TBI and that its effects may be broad, with alterations in neurogenesis and synaptogenesis.

Elevated inflammatory biomarkers and poor outcomes in intracerebral hemorrhage.

BACKGROUND: Accumulating evidence suggests that spontaneous intracerebral hemorrhage (ICH) is associated with a reactive neuroinflammatory response. However, it remains unclear if circulating inflammatory biomarkers are associated with adverse outcomes in ICH. To address this knowledge gap, we conducted a cohort study using a prospectively maintained stroke register in the United Kingdom to assess the prognostic value of admission inflammatory biomarkers in ICH. METHODS: The Norfolk and Norwich Stroke and TIA Register recorded consecutive ICH cases. The primary exposures of interest were elevation of white cell count (WCC; > 10 × 109/L), elevation of c-reactive protein (CRP; > 10 mg/L), and co-elevation of both biomarkers, at the time of admission. Modified Poisson and Cox regressions were conducted to investigate the relationship between co-elevation of WCC and CRP at admission and outcomes following ICH. Functional outcome, multiple mortality timepoints, and length of stay were assessed. RESULTS: In total, 1714 ICH cases were identified from the register. After adjusting for covariates, including stroke-associated pneumonia, co-elevation of WCC and CRP at admission was independently associated with significantly increased risk of poor functional outcome (RR 1.08 [95% CI 1.01-1.15]) and inpatient mortality (RR 1.21 [95% CI 1.06-1.39]); and increased 90-day (HR 1.22 [95% CI 1.03-1.45]), and 1-year mortality (HR 1.20 [95% CI 1.02-1.41]). Individual elevation of WCC or CRP was also associated with poor outcomes. CONCLUSIONS: Elevated inflammatory biomarkers were associated with poor outcomes in ICH. This study indicates that these readily available biomarkers may be valuable for prognostication and underscore the importance of inflammation in ICH.

Medical Malpractice and Vestibular Schwannomas: A Nationwide Review.

OBJECTIVE: Most surgeons face litigation related to the care of their patients, with specialties including neurosurgery facing a particularly high risk. Diagnosis and management of vestibular schwannomas can be challenging, potentially giving rise to medicolegal proceedings. Accordingly, a full appreciation of the medicolegal implications of treating these challenging tumors is warranted. METHODS: A systematic search of the Westlaw Edge legal database was conducted to identify all cases of medicolegal proceedings related to the management of vestibular schwannomas. All cases identified by the search were screened in full, and relevant cases included for analysis. Variables pertaining to the nature of the case and legal outcomes were extracted. RESULTS: A total of 38 cases were included in this analysis from 11 U.S. states. Failure to diagnose and negligent surgery were the most common allegations. Neurosurgeons were the most frequently implicated specialists followed by otolaryngologists and radiologists. A verdict was reached in 30 cases, with the jury finding in favor of the defendant(s) in most cases (n = 26, 87.0%), a proportion that increased across each decade of the study period. Damages were paid out in 11 cases, with a mean value of $1,534,446. Mean value of damages paid in verdicts in favor of the plaintiff were larger than those in settlements ($2,116,543 and $1,385,457, respectively). CONCLUSIONS: The data presented provide a comprehensive overview of medicolegal proceedings related to the management of vestibular schwannomas. This study provides clinicians with a greater appreciation of the medicolegal implications of treating vestibular schwannomas.

Open craniofacial reconstruction for coronal craniosynostosis.

Here the authors demonstrate open craniofacial reconstruction for the correction of craniosynostosis, using techniques refined by Dr. James T. Goodrich at Montefiore Medical Center. They present the operative management of a case of unilateral coronal synostosis in a 12-month-old child, who presented with right forehead prominence and calvarial asymmetry. The patient had an excellent correction of her head shape with an uneventful postoperative course. This video highlights the authors' multidisciplinary approach to complete cranial vault remodeling, utilizing a Marchac bandeau construct and split calvarial graft mosaic technique. The video can be found here: https://vimeo.com/519489422.

COVID-19 Infection Among Healthcare Workers: Serological Findings Supporting Routine Testing.

A growing body of evidence demonstrates that asymptomatic and pre-symptomatic transmission of SARS-CoV-2 is a major contributor to the COVID-19 pandemic. Frontline healthcare workers in COVID-19 hotspots have faced numerous challenges, including shortages of personal protective equipment (PPE) and difficulties acquiring clinical testing. The magnitude of the exposure of healthcare workers and the potential for asymptomatic transmission makes it critical to understand the incidence of infection in this population. To determine the prevalence of asymptomatic SARS-CoV-2 infection amongst healthcare workers, we studied frontline staff working in the Montefiore Health System in New York City. All participants were asymptomatic at the time of testing and were tested by RT-qPCR and for anti-SARS-CoV-2 antibodies. The medical, occupational, and COVID-19 exposure histories of participants were recorded via questionnaires. Of the 98 asymptomatic healthcare workers tested, 19 (19.4%) tested positive by RT-qPCR and/or ELISA. Within this group, four (4.1%) were RT-qPCR positive, and four (4.1%) were PCR and IgG positive. Notably, an additional 11 (11.2%) individuals were IgG positive without a positive PCR. Two PCR positive individuals subsequently developed COVID-19 symptoms, while all others remained asymptomatic at 2-week follow-up. These results indicate that there is considerable asymptomatic infection with SARS-CoV-2 within the healthcare workforce, despite current mitigation policies. Furthermore, presuming that asymptomatic staff are not carrying SARS-CoV-2 is inconsistent with our results, and this could result in amplified transmission within healthcare settings. Consequently, aggressive testing regiments, such as testing frontline healthcare workers on a regular, multi-modal basis, may be required to prevent further spread within the workforce and to patients.