Demographics of focused ultrasound thalamotomy for essential tremor and trends in deep brain stimulation surgery after its introduction in the USA.

Background: Essential tremor (ET) is a movement disorder that affects 4%-5% of adults >65 years. For patients with medically refractory ET, neurosurgical interventions such as deep brain stimulation (DBS) and unilateral MR-guided focused ultrasound thalamotomy (MRgFUS) are available. In this retrospective cohort study, we examined the demographics of patients with ET who have received MRgFUS and evaluated trends in DBS usage in the USA after the introduction of MRgFUS in 2016. Methods: We used multiple databases to examine the demographics of patients who received DBS and MRgFUS, and trends in DBS. To assess the demographics, we queried the TriNetX database from 2003 to 2022 to identify patients diagnosed with ET and stratify them by DBS or MRgFUS treatment by using Current Procedural Terminology codes. Patient demographics were reported as frequencies and percentages. To examine the trends in DBS for ET, the yearly frequency of DBS procedures done for ET between 2012 and 2019 was extracted from the National Inpatient Sample (NIS) database, and breakpoint analysis was performed. Additionally, the yearly frequency of MRgFUS procedures for ET was obtained from Insightec Exlabate. Results: Most of the patients (88.69%) in the cohort extracted from TriNetX database self-identified as white, followed by black or African American (2.40%) and Asian (0.52%). A higher percentage of black patients received MRgFUS treatment than DBS (4.10% vs 1.88%). According to the NIS database, from 2012 to 2020, 13 525 patients received DBS for ET. Conclusion: This study provides an overview of the characteristics of patients who undergo DBS or MRgFUS. We found notable differences in sex and race among patients who underwent each treatment type. Additionally, until at least the beginning of 2020, the number of DBS procedures for ET was not negatively affected after the introduction of MRgFUS.

Coincident parkinsonism and myasthenia gravis: A case series.

After querying our institution's electronic health record system for patients with primary parkinsonism and myasthenia gravis (MG), we report the cases of 15 patients with Parkinson disease and MG, and a case of Dementia with Lewy Bodies and MG.

Disparities in diagnosis, treatment and survival between Black and White Parkinson patients.

INTRODUCTION: Racial disparities in diagnosis, treatment and survival in Black patients with Parkinson's disease (PD) compared to White patients have not been well studied, largely due to limited number of studies and information on Black patients in healthcare systems. Studying racial disparities and identifying underlying factors in large populations are important to understand PD and improve care. METHODS: We retrospectively identified PD patients on both races from 1/1/2006 to 10/31/2017 and compared demographics, socioeconomic status (educations, incomes and insurances), comorbidities (all categories, including mood, cognition and psychosis), treatment (medications for parkinsonism and major non-motor symptoms, and frequency and locations of healthcare) and survival, and identified factors associated with medication usage and survival. RESULTS: We retrospectively studied 2033 PD patients, of whom 725 were Black. Black patients lacked male predominance, were 4 years older at first diagnosis here, more likely to smoke and live in a low education and income community, and possessed limited insurances compared to White patients. Black patients also had more comorbidities and were more likely to receive care through emergency or inpatient service, but less likely to be on medications for parkinsonism and mood disorders. Race, age, smoking status, insurance type, frequency and locations of healthcare and comorbidities were associated with medication usage. Black race, older age, inpatient admission and malignancy were associated with increased risk of death. CONCLUSION: We revealed racial disparities in diagnosis, treatment and survival, and factors associated with medication usage and survival in the largest reported Black PD cohort from a single center.

Improving Incident Reporting Among Physician Trainees.

BACKGROUND: Preventable medical harm is a leading cause of death in the United States. Incident reporting systems have been identified as the primary method to capture medical error and harm. Incidents are rarely reported, particularly among physician trainees. METHODS: We conducted a single-center, quasi-experimental study to examine the effect of education on the importance of and how to file an incident report for physician trainees on reporting rates. Trainees were provided laminated plastic instructions, and reporting was reinforced with weekly patient safety rounds. In addition, trainees completed anonymous surveys preintervention and postintervention to determine barriers to reporting. A χ test compared the number of reports preintervention and postintervention. RESULTS: For 6 months, 73 resident physicians participated in the study. Median incident reports entered by trainees increased from 1 report per month during the preintervention period to 10 reports per month after the intervention (P = 0.005). The most common barriers to reporting incidents before intervention were not knowing how to report (72.6%), what to report (56.2%), and lack of time (42.5%). A total of 13.7% reported fear of retaliation. Most incident reports were due to delay in patient care (40.9%) and medical errors (33.3%). CONCLUSIONS: Real-time education and regular reinforcement increased incident reporting among resident physicians. This educational approach may increase incidence reporting in other institutions.

Revisiting bilateral thalamotomy for tremor.

MRI guided focused ultrasound surgery (MRgFUS) has been FDA approved for unilateral treatment of essential tremor (ET). Before this non-incisional lesioning method can be applied to the treatment of both hemispheres the previous experience with bilateral thalamic ablation must be addressed. In particular, the high incidence of worsening of speech and balance associated with bilateral surgical thalamotomy, a rationale for the development of deep brain stimulation. The highest incidence of these complication occurred in the early years of surgery for movement disorders, when neither MRI nor current stereotactic methods were available. The vast majority of these initial patients suffering these complications had Parkinson's disease where approximately 30% developed worsening dysarthria and ataxia after bilateral thalamotomy. Patients suffering these complications commonly had baseline abnormalities in speech and balance or worsening symptoms after a first unilateral procedure. The more contemporary experience with bilateral thalamotomy in the ET population is both much more limited in patient numbers (includes patients after Gamma Knife radiosurgery), and shows a much lower rate of these complications (approximately 5%). This more recent experience suggests that bilateral thalamotomy using closed incisionless methods such as MRgFUS has the potential to safely improve ET patients with axial or bilateral limb involvement, if done in a staged manner excluding patients with baseline dysarthria or ataxia or transient worsening of these symptoms following a unilateral procedure.

Thymectomy is safe for myasthenia gravis patients: Analysis of the NSQIP database.

INTRODUCTION: The aim of this study was to determine thymectomy-associated morbidity and mortality outcomes among myasthenia gravis (MG) patients. METHODS: Patients undergoing thymectomy were identified from the National Surgical Quality Improvement Program database from 2005 to 2012 using Current Procedural Terminology codes. Patient demographics, clinical characteristics, and postoperative outcomes were stratified by MG diagnosis. Logistic regression was used to identify predictors for morbidity outcomes. The chi-square test was used to examine the association between MG diagnosis and surgical approach. RESULTS: A total of 1,148 subjects underwent thymectomy, and 108 had MG. Compared with control subjects, MG patients had a more severe American Society of Anesthesiologists physical classification and frailty index score, greater corticosteroid usage, and a higher rate of reintubation. There were no deaths among MG patients. The majority of MG patients underwent transsternal thymectomy. CONCLUSION: Although patients with MG have a greater preoperative morbidity and a higher frequency of reintubation, thymectomy was found to be a safe procedure overall.