Computational Barthel Index: an automated tool for assessing and predicting activities of daily living among nursing home patients.

BACKGROUND: Assessment of functional ability, including activities of daily living (ADLs), is a manual process completed by skilled health professionals. In the presented research, an automated decision support tool, the Computational Barthel Index Tool (CBIT), was constructed that can automatically assess and predict probabilities of current and future ADLs based on patients' medical history. METHODS: The data used to construct the tool include the demographic information, inpatient and outpatient diagnosis codes, and reported disabilities of 181,213 residents of the Department of Veterans Affairs' (VA) Community Living Centers. Supervised machine learning methods were applied to construct the CBIT. Temporal information about times from the first and the most recent occurrence of diagnoses was encoded. Ten-fold cross-validation was used to tune hyperparameters, and independent test sets were used to evaluate models using AUC, accuracy, recall and precision. Random forest achieved the best model quality. Models were calibrated using isotonic regression. RESULTS: The unabridged version of CBIT uses 578 patient characteristics and achieved average AUC of 0.94 (0.93-0.95), accuracy of 0.90 (0.89-0.91), precision of 0.91 (0.89-0.92), and recall of 0.90 (0.84-0.95) when re-evaluating patients. CBIT is also capable of predicting ADLs up to one year ahead, with accuracy decreasing over time, giving average AUC of 0.77 (0.73-0.79), accuracy of 0.73 (0.69-0.80), precision of 0.74 (0.66-0.81), and recall of 0.69 (0.34-0.96). A simplified version of CBIT with 50 top patient characteristics reached performance that does not significantly differ from full CBIT. CONCLUSION: Discharge planners, disability application reviewers and clinicians evaluating comparative effectiveness of treatments can use CBIT to assess and predict information on functional status of patients.

Management and Outcomes of Spontaneous Pneumomediastinum in Children.

OBJECTIVES: Management of spontaneous pneumomediastinum in the pediatric population is highly variable. There are limited data on the use of diagnostic tests and the need for admission. Our objectives were to characterize the management of pediatric spontaneous pneumomediastinum, determine the diagnostic yield of advanced imaging, and describe the patients' outcomes. METHODS: This is a retrospective cohort study of all patients presenting to a single tertiary pediatric emergency department between January 2008 and February 2015 diagnosed with pneumomediastinum. Patients were identified using 2 complementary strategies: International Classification of Diseases, Ninth Revision billing codes and a keyword search of the hospital radiology database. RESULTS: We identified 183 patients with spontaneous pneumomediastinum. The mean age was 12.8 ± 4.8 years. Diagnosis was established by chest radiograph (CXR) in 165 (90%) patients, chest computed tomography in 15 (8%), neck imaging in 2 (1%), and abdominal imaging in 1. After diagnosis, many patients underwent additional studies: repeat CXR (99, 54%), chest computed tomography (53, 29%), esophagram (45, 25%), and laryngoscopy (15, 8%). Seventy-eight percent of patients (n = 142) were admitted with a median length of stay of 27 hours (18.4-45.6 hours). Six patients returned to the emergency department within 96 hours for persistent chest pain; 2 were admitted, and 1 was found to have worsening pneumomediastinum on CXR. We performed a secondary analysis on 3 key subgroups: primary spontaneous pneumomediastinum (64, 35%), secondary gastrointestinal-associated pneumomediastinum (31, 17%), and secondary respiratory-associated pneumomediastinum (88, 48%). No patients in the study received an invasive intervention for pneumomediastinum. In all patients, further studies did not yield additional diagnostic information. CONCLUSIONS: Our data suggest that patients with spontaneous pneumomediastinum who are clinically well appearing can be managed conservatively with clinical observation, avoiding exposure to radiation and invasive procedures.

Microbes and animal olfactory communication: Where do we go from here?

We know that microbes contribute to the production of odors that some animals use to communicate, but how common is this phenomenon? Recent studies capitalizing on new molecular technologies are uncovering fascinating associations between microbes and odors of wild animals, but causality is difficult to ascertain. Fundamental questions about the nature of these unique host-microbe interactions also remain unanswered. For instance, do microbes benefit from signaling associations with hosts? How does microbial community structure influence signal production? How do hosts regulate microbes in order to generate appropriate signals? Here, we review the current state of knowledge on microbially produced signals in animals and discuss key research foci that can advance our understanding of microbial-based signaling in the animal world.

Risk factors for surgical complications in rotator cuff repair in a veteran population.

BACKGROUND: Technical advances have allowed arthroscopic rotator cuff repair to supplant open repairs with similar outcomes. However, few data exist to support the theoretical decrease in complications with the arthroscopic technique. METHODS: We used the Veterans Administration Surgical Quality Improvement Program database from the entire U.S. Veterans Administration system. We obtained perioperative data of all patients undergoing rotator cuff repair between 2003 and 2008. Single and multivariate analyses were performed to evaluate risk factors for perioperative complications associated with rotator cuff surgery. RESULTS: There were 6975 open rotator cuff repairs and 2918 arthroscopic rotator cuff repairs performed with similar patient age, gender breakdown, body mass index, and comorbidities. Complications occurred in the early postoperative period in 2.1% of the open repair group and 0.9% of the arthroscopic repair group (P < .0001). The prevalence of both superficial and deep wound infection was higher in the open group compared with the arthroscopic group (1% vs. 0.1% superficial, P < .0001; 0.3% vs. 0.1% deep, P = .11). Return to the operating room within the 30-day surveillance period occurred in 1.1% of the open repair patients compared with 0.5% of patients undergoing arthroscopic repairs (P < .0001). -Multivariate logistic regression analysis revealed that the arthroscopic group had a significantly lower risk of complications (P = .0001), a lower rate of superficial infection (P = .0002), a lower incidence of return to the operating room within 30 days (P = .007), and a lower risk of hospital readmission (P < .0001). CONCLUSION: Arthroscopic rotator cuff repair in the veteran population resulted in a lower incidence of perioperative complications compared with open repair.

Relationship of relaxin hormone and thumb carpometacarpal joint arthritis.

BACKGROUND: The female predominance in thumb carpometacarpal (CMC) joint arthritis has led to speculation that reproductive hormones or hypermobility are responsible. Evidence shows that patients with pathologic laxity have a higher rate of thumb CMC arthritis. Relaxin hormone increases laxity in the pelvic ligaments through upregulation of matrix metalloproteases (MMPs). It is thus a hormone of interest in the development of thumb CMC arthritis. QUESTIONS/PURPOSES: Our goals were to identify demographic and hormonal factors associated with joint laxity in patients with CMC arthritis and to evaluate the relationship among serum relaxin, relaxin receptors, and MMPs in the anterior oblique ligament (AOL) of the thumb. We hypothesized that serum relaxin was correlated with joint laxity as well as with relaxin receptors and MMPs in the AOL. METHODS: Forty-nine patients undergoing thumb CMC arthroplasty underwent laxity examination, blood draw, and AOL sampling. Ligaments were analyzed for relaxin receptor and MMPs 1 and 3 using quantitative reverse-transcriptase polymerase chain reaction. RESULTS: Women demonstrated more joint laxity than men (p < 0.001). RNA analysis confirmed relaxin receptors in the AOL as well as MMPs 1 and 3. There was a significant correlation between serum relaxin and MMP-1 (p = 0.04). Detectable serum relaxin was negatively correlated with relaxin receptors in the AOL (p = 0.02). CONCLUSIONS: Further studies are needed to evaluate the role of laxity and sex hormones in thumb CMC arthritis. CLINICAL RELEVANCE: Relaxin hormone may play a role in the development of arthritis at the thumb CMC joint. LEVEL OF EVIDENCE: Level I, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Veterans with diabetes receive arthroplasty more frequently and at a younger age.

BACKGROUND: A future increase in total joint arthroplasties in patients with diabetes seems likely considering the prevalence of osteoarthritis and diabetes mellitus are increasing. However, the rates of arthroplasty in the population of patients with diabetes are unclear. QUESTIONS/PURPOSES: We sought to determine whether lower extremity arthroplasties in a veteran population with diabetes is different from a similar population without diabetes. The following specific questions were asked: (1) Is the rate of TKA in veterans with diabetes higher than in those without diabetes? (2) Is the rate of THA in veterans with diabetes higher than in those without diabetes? (3) Are arthroplasty revision rates greater in veterans with diabetes than in veterans without diabetes? METHODS: The US Department of Veterans Affairs Health administrative data from fiscal year 2000 was used to identify persons with primary or secondary TKA or THA. The rate of surgeries among a diabetic population was compared with that among a nondiabetic population. RESULTS: The diabetic cohort received total joint arthroplasties at a higher rate than the nondiabetic cohort at all ages younger than 66 years, with a range of odd ratios from 1.3 to 3.4. In answer to our specific questions, (1) the rate of TKA (95% CI, 2.1-3.7), (2) the rate of THA (95% CI, 1.0-2.6), and (3) the rates of arthroplasty revision (95% CI, 0.9-5.8 TKA and 0.7-6.8 THA) were higher in veterans with diabetes. Furthermore, those with diabetes in the youngest age group studied received total joint arthroplasties and revision surgeries at approximately double the rates of those without diabetes. CONCLUSIONS: If these findings hold true for the population as a whole, they imply that clinicians in the United States may see a sharp increase in younger diabetic candidates for joint arthroplasty.

Relationship of serum relaxin to generalized and trapezial-metacarpal joint laxity.

PURPOSE: The reproductive hormone relaxin acts to loosen pelvic ligaments in preparation for childbirth and is thought to be a mediator of joint laxity. The purpose of this study was to evaluate the correlation of serum relaxin with radiographic laxity at the trapezial-metacarpal joint and with generalized joint laxity. METHODS: We enrolled 289 healthy subjects prospectively. Participants completed a demographic questionnaire and were examined for generalized joint hypermobility using the Beighton-Horan scale. Stress radiographs of the trapezial-metacarpal joint were obtained in 163 subjects (56%). Blood samples were collected, and serum relaxin was measured for 287 subjects using enzyme-linked immunosorbent assay for human relaxin-2. RESULTS: The mean serum relaxin level among all subjects was 1.84 pg/mL (range, 0-45.25 pg/mL). Relaxin was not detectable in 166 of 287 samples, whereas the mean serum relaxin level among the 121 subjects with a detectable relaxin level (of 287 total relaxin samples) was 4.37 pg/mL (range, 0.46-45.25 pg/mL). Mean trapezial-metacarpal subluxation ratio scores were higher among those with a detectable relaxin level compared to those without a detectable relaxin level (0.34 vs 0.30 pg/mL). The average Beighton-Horan laxity score was 1.8 (range, 0-9). There was no correlation between generalized joint laxity measures and serum relaxin levels. CONCLUSIONS: In a large volunteer population, we demonstrated a relationship between circulating relaxin and trapezial-metacarpal joint laxity. However, we were unable to show a direct link between serum relaxin and generalized joint laxity. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Comparison of autologous blood, corticosteroid, and saline injection in the treatment of lateral epicondylitis: a prospective, randomized, controlled multicenter study.

PURPOSE: We compared saline, corticosteroid, and autologous blood injections for lateral epicondylitis in a prospective, blinded, randomized, controlled trial. The null hypothesis was that patient-rated outcomes after autologous blood injection would not be superior to corticosteroid and saline injections. METHODS: Patients with clinically diagnosed lateral epicondylitis of less than 6 months' duration were randomized into 1 of 3 groups to receive a 3-mL injection of saline and lidocaine, corticosteroid and lidocaine, or autologous blood and lidocaine. Of 34 subjects who enrolled, 28 completed follow-up. A total of 10 were randomized to the saline group, 9 to the autologous blood group, and 9 to the steroid group. Every participant had 3 mL blood drawn, and the injection syringe was foil-covered to prevent the subject from knowing the contents. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Patients completed a pain visual analog scale, DASH, and the Patient-Rated Forearm Evaluation before injection and at 2 weeks, 2 months, and 6 months after injection. We performed statistical analysis using repeated measures of analyses of variance. RESULTS: There were no significant differences in DASH scores among the 3 groups at 2- and 6-month follow-up points, with the mean scores for saline at 20 and 10, respectively, compared with 28 and 20 for autologous blood and 28 and 13 for steroid injections. Secondary measures showed similar findings, with outcomes scores showing improvement in all 3 groups. CONCLUSIONS: In this prospective, randomized, controlled trial, autologous blood, corticosteroid, and saline injection provide no advantage over placebo saline injections in the treatment of lateral epicondylitis. Patients within each injection group demonstrated improved outcome scores over a 6-month period.

Safety and efficacy of damage control external fixation versus early definitive stabilization for femoral shaft fractures in the multiple-injured patient.

BACKGROUND: Optimal timing and treatment of patients with concomitant head, thoracic, or abdominal injury and femoral shaft fracture remain controversial. This study examines acute patient outcomes associated with early total care with intramedullary nailing (ETC group) versus damage control external fixation (DCO group) for multiple-injured patients with femoral shaft fractures. We propose DCO as a safe initial treatment for the multiple-injured patient with femur shaft fractures. METHODS: This study was a retrospective review of the trauma registry and multisystem organ failure registry data at a Level I trauma center. Two cohorts were identified to compare multiple-injured patients with femoral shaft fractures treated with early total care and damage control orthopaedic surgery. Primary outcome measures included mortality, pulmonary complications (adult respiratory distress syndrome [ARDS] score), transfusion requirements, and multiple organ failure (MOF score). Operative time, estimated blood loss, intensive care unit length of stay (LOS), and hospital length of stay (LOS) were also compared. RESULTS: During the study period, 462 patients with 481 femoral shaft fractures were identified. Of 462 patients with femoral shaft fractures, 97 met the inclusion criteria (42 ETC and 55 DCO). The DCO group had a significantly shorter operative time (22 minutes vs. 125 minutes) and less estimated blood loss from their operative procedure (37 mL vs. 330 mL). There was no significant difference between the groups for ARDS, lung scores, MOF, MOF score, intensive care unit LOS, or hospital LOS. CONCLUSION: Fracture fixation method did not have an impact on the incidence of systemic complications in multiple-injured patients with femoral shaft fractures. Although minimal differences were noted between DCO and ETC groups regarding systemic complications, DCO is a safer initial approach, significantly decreasing the initial operative exposure and blood loss.

Posttraumatic stress disorder and depression negatively impact general health status after hand injury.

PURPOSE: To estimate the prevalence of posttraumatic stress disorder (PTSD) and depression among hand-injured patients and assess the impact of these disorders on general health status. METHODS: A total of 106 adult hand-injured patients (40 women, 66 men) with a mean age of 42 years (range, 18-79 years) participated. Patients with a chronic mental illness or cognitive impairment were excluded. Psychological status was assessed using the Revised Civilian Mississippi Scale for PTSD and the Beck Depression Inventory. General health status was evaluated with the Short Form-36 health survey (SF-36). We obtained demographics and injury characteristics from the patient medical records. RESULTS: Prominent mechanisms of injury included a fall (n = 38), traffic-related injuries (n = 14), machine versus operator (n = 8), gunshot wounds (n = 6), and assault (n = 6). Using the screening questionnaires, 32 persons qualified for PTSD and 19 for depression. Sixteen patients met the criteria for both PTSD and depression. The association between PTSD and depression was significant (p < .01). Patients with PTSD had significantly lower scores than those who did not endorse items consistent with PTSD or depression on the SF-36 subscales of role-emotional (p < .01), body pain (p = .013), social function (p = .028), and mental health (p < .01). We found no significant differences between groups for the subscales of role-physical (p = .289), general health (p = .147), vitality (p = .496), and physical functioning (p = .476). Patients who had concurrent PTSD and depression had significantly lower scores than patients who had neither PTSD nor depression on all subscales (p < .05 for all) except role-physical (p = .135). We found significant negative correlations between Beck Depression Inventory scores and all of the SF-36 subscales (p < .05 for all). CONCLUSIONS: In this study, nearly one third of hand-injured patients met diagnostic criteria for PTSD, depression, or both, according to the thresholds of the instruments used to measure these psychological aspects of illness. PTSD and depression had a negative effect on general health status after hand injury. It may be important to consider psychological status when caring for patients with hand injuries.

Treatment of distal femur and proximal tibia fractures with external fixation followed by planned conversion to internal fixation.

PURPOSE: To evaluate healing rates and complications in patients treated with temporary external fixation (EF) and subsequent open reduction and internal fixation (ORIF) for high-energy distal femur or proximal tibia fractures. METHODS: Retrospective analysis of prospectively collected data 1999 to 2005. Demographic data and injury severity score were obtained from medical records. Factors reviewed included perioperative complications (nonunion, postoperative infection, loss of fixation) and time to radiographic and clinical union. RESULTS: Forty-seven patients with 16 distal femur and 36 proximal tibia fractures were treated using temporary EF. Patients subsequently underwent ORIF (mean time from EF to ORIF = 5 days, range 1-23 days). Thirty-five fractures were open (Gustilo I = 8, II = 6, IIIA = 3, IIIB = 13, IIIC = 5) and 17 closed. Forty patients with 44 fractures reached 1-year follow-up. Of these, 36 patients with 40 (91%) fractures had healed both radiographically and clinically. The mean postoperative follow-up time was 14 months (range 3-68). Eight (16%) deep infections occurred, all in open fractures (Gustilo I = 2, IIIB = 3, IIIC = 3), with one patient requiring above knee amputation. Other complications included one hematoma, two malunions, one fixation failure, and one pin site infection. One patient died as a result of a stroke. CONCLUSIONS AND SIGNIFICANCE: Temporary bridging EF offers the advantage of early soft tissue and bone stabilization without the potential local risks of immediate ORIF in severely injured soft tissues, or the potential systemic risks in a severely traumatized patient. The 16% infection rate in this study, all occurring in open fractures, falls within the reported range for grade III open fractures (15%-20%). We conclude that the initial treatment of high-energy periarticular knee fractures with bridging EF, followed by planned conversion to internal fixation is a safe option in patients who are unsuitable for initial definitive surgery.

Serum titanium levels in individuals undergoing intramedullary femoral nailing with a titanium implant.

BACKGROUND: Many patients request nail extraction or question the long-term effects of hardware retention. Systemic titanium degradation products may influence the timing of such decisions. The orthopedic literature provides no data regarding systemic titanium in patients undergoing intramedullary nail fixation with titanium implants. The purpose of this study was to determine the systemic level of serum titanium in patients who had undergone femoral nailing. METHODS: Patients who underwent antegrade locked femoral nailing utilizing a reamed technique with a titanium implant were eligible to participate. Eight patients were recruited for each of four time points: 6 weeks, 3 months, 6 months, and 1 year. Blood samples were collected from each subject. Serum titanium levels were analyzed through inductively coupled plasma/mass spectrometry (ELAN DRC II, Perkin Elmer, SCIEX, Inc, Shelton, CT). Test sensitivity was 0.2 microg/L. Normal serum titanium levels are <150 microg/L. RESULTS: Thirty-two patients were enrolled. The study group included 10 women and 22 men with average age of 32 (range 19-63) years. The most common fracture pattern was 32-A3 (n = 12), followed by 32-B2 (n = 9). No patients showed an elevated serum titanium level. Mean titanium levels were 49.38, 58.25, 49.38, and 50.63 microg/L at 6 weeks, 3 months, 6 months, and 12 months cohorts, respectively. No statistically significant differences were found (p = 0.207). CONCLUSIONS: Standard intramedullary nail fixation of femur fractures did not result in elevated levels of serum titanium in the first year after surgery. Differences in serum titanium did not differ significantly across time since implantation.

Ethnic differences in posttraumatic stress disorder after musculoskeletal trauma.

BACKGROUND: Psychological distress is known to contribute to poor outcomes in orthopedic patients. Limited information exists concerning ethnic differences in psychological sequelae after musculoskeletal injury. This study examined ethnic variations in prevalence of posttraumatic stress disorder (PTSD) after musculoskeletal trauma. METHODS: A secondary analysis was conducted using data collected for a study examining PTSD after musculoskeletal trauma. Two hundred eleven consecutive patients with musculoskeletal injuries were enrolled. Psychological status was assessed using the Revised Civilian Mississippi Scale for PTSD. A chart review was completed to gather demographic and injury information. Independent samples t tests, Fisher's exact, Chi-square, and logistic regression analyses were performed to assess differences. RESULTS: Ninety-six (45.5%) Hispanic and 115 (54.5%) non-Hispanic White adults participated. Few significant demographic or health differences were found. No significant differences were found regarding injury characteristics. Fisher's exact tests indicated a higher prevalence of PTSD symptomatology among Hispanics than non-Hispanic Whites (p < 0.01). Additionally, U.S. born Hispanics were more likely than non-U.S. born Hispanics to have PTSD symptomatology (p = 0.004). Odds ratios indicated that women (OR = 2.2), persons with a psychiatric comorbidity (OR = 5.1), Hispanics (OR = 6.6), and persons born in the United States (OR = 3.7) had an increased likelihood of PTSD symptomatology. CONCLUSIONS: Results indicate an ethnic difference in prevalence of PTSD symptomatology after musculoskeletal injury. Hispanic participants were nearly seven times more likely to be positive for PTSD symptomatology. Furthermore, U.S. born Hispanic participants had a higher prevalence of PTSD symptomatology. Future research should explore factors contributing to these differences.

Myelopathy Improvement Following Removal of Cervical Sublaminar Wiring.

Posterior cervical wiring has been used by spine surgeons in fixation procedures for patients with spinal instability. It is historically considered an effective method of treating cervical instability with a low risk of complications leading to neurological deterioration. We experienced a case of delayed neurological decline associated with myelopathy, lower extremity spasticity, and associated syringomyelia secondary to instrumentation failure and resultant sublaminar wire protrusion into the cervical spinal cord. In the present case, the construct was removed and the patient underwent a durotomy repair and a posterior fusion of cervical levels 1 and 2 via screw placement under image guidance with a subsequent functional improvement back to baseline. We report this case and review the literature on the complications associated with cervical wire fusion and the methods of minimizing these risks.

Budget Impact Analysis of Veterans Affairs Medical Foster Homes versus Community Living Centers.

The objectives were to determine whether and by what amounts the US Department of Veterans Affairs (VA) use of Medical Foster Homes (MFH) rather than Community Living Centers (CLC) reduced budget impacts to the VA. This was a retrospective, matched, case-control study of veterans residing in MFH or CLC in the VA health care system from 2008 to 2012. Administrative data sets, nearest neighbor matching, generalized linear models, and a secondary analysis were used to capture and analyze budget impacts by veterans who used MFH or CLC exclusively in 2008-2012. Controls of 1483 veterans in CLC were matched to 203 cases of veterans in MFH. Use of MFH instead of CLC reduced budget impacts to the VA by at least $2645 per veteran per month. A secondary analysis of the data using different matching criteria and statistical methods produced similar results, demonstrating the robustness of the estimates of budget impact. When the average out-of-pocket payments made by MFH residents, not made by CLC residents, were included in the analysis, the net reduction of budget impact ranged from $145 to $2814 per veteran per month or a savings of $1740 to $33,768 per veteran per year. Even though outpatient costs of MFH are higher, much of the reduced budget impact of MFH use arises from lower inpatient or hospital costs. Reduced budget impacts on the VA system indicate that expansion of the MFH program may be cost-effective. Implications for further research are suggested.

Simultaneous Resection of Multiple Metastatic Brain Tumors with Multiple Keyhole Craniotomies.

BACKGROUND: The proper management of symptomatic patients with 2 or more brain metastases is not entirely clear, and the surgical outcomes of these patients undergoing multiple simultaneous craniotomies have not been well described. In this article, we describe patient outcomes after simultaneously resecting metastatic lesions through multiple keyhole craniotomies. METHODS: We conducted a retrospective review of data obtained for all patients undergoing resection of multiple brain metastases in one operation between 2014 and 2016. We describe a technique for resecting multiple metastatic lesions and share the patient outcomes of this operation. RESULTS: Twenty patients with 46 tumor resections were included in the study. The primary site of metastases for the majority of patients was lung, followed by melanoma, renal, breast, colon, and testes. Nine of 20 (45%) patients had 2 preoperative intracranial lesions, and 11 (55%) had three or more. Karnofsky performance scales were calculated for 14 patients: postoperatively 10 of 14 (71%) scores improved, 2 of 14 (14%) worsened, and 2 of 14 (14%) remained unchanged. After surgery, 9 of 14 (64%) patients were weaned off steroids by 2-month follow-up. The overall median survival time from date of surgery was 10.8 months. CONCLUSIONS: We present patient outcomes after simultaneously resecting metastatic brain tumors through multiple keyhole craniotomies in symptomatic patients. Our results suggest comparable outcomes and similar surgical risk compared with those undergoing resection of a single brain metastasis. Resection of multiple brain metastases may improve Karnofsky Performance Scale scores in the early postoperative period and allow patients to be weaned from steroids.