RESUMO
OBJECTIVES: Prone positioning has been shown to be a beneficial adjunctive supportive measure for patients who develop acute respiratory distress syndrome. Studies have excluded patients with reduced intracranial compliance, whereby patients with concomitant neurologic diagnoses and acute respiratory distress syndrome have no defined treatment algorithm or recommendations for management. In this study, we aim to determine the safety and feasibility of prone positioning in the neurologically ill patients. DESIGN AND SETTING: A systematic review of the literature, performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses 2009 guidelines, yielded 10 articles for analysis. Using consensus from these articles, in combination with review of multi-institutional proning protocols for patients with nonneurologic conditions, a proning protocol for patients with intracranial pathology and concomitant acute respiratory distress syndrome was developed. MEASUREMENTS AND MAIN RESULTS: Among 10 studies included in the final analysis, we found that prone positioning is safe and feasible in the neurologically ill patients with acute respiratory distress syndrome. Increased intracranial pressure and compromised cerebral perfusion pressure may occur with prone positioning. We propose a prone positioning protocol for the neurologically ill patients who require frequent neurologic examinations and intracranial monitoring. CONCLUSIONS: Although elevations in intracranial pressure and reductions in cerebral perfusion pressure do occur during proning, they may not occur to a degree that would warrant exclusion of prone ventilation as a treatment modality for patients with acute respiratory distress syndrome and concomitant neurologic diagnoses. In cases where intracranial pressure, cerebral perfusion pressure, and brain tissue oxygenation can be monitored, prone position ventilation should be considered a safe and viable therapy.
Assuntos
Encéfalo/irrigação sanguínea , Cuidados Críticos/métodos , Decúbito Ventral , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório/terapia , Protocolos Clínicos , Humanos , Posicionamento do Paciente/métodosRESUMO
OBJECTIVE: To celebrate the increasing representation of women as leaders in American surgery and provide suggestions for increasing diversity in leadership. BACKGROUND: Women were barred from entering the practice of medicine or surgery until the mid 1800's when Elizabeth Blackwell led the way as the first woman admitted to medical school. Although the numbers of women practicing medicine and surgery have increased exponentially since Dr Blackwell graduated, the number of women in leadership positions has remained low until recently. METHODS: An analysis of the literature on the history of women in surgery and the websites of the major surgical societies. RESULTS: More women are now rising to leadership positions in surgery, both in academics and within surgical organizations. The American College of Surgeons and many other surgical societies, as well as an increasing number of academic departments of surgery have realized that women can be inspiring and capable leaders. However, increasing the number of under-represented minority women in leadership positions remains an opportunity for improvement. CONCLUSIONS: Great progress has been made in the advancement of women into leadership positions in surgery. To continue this trend and increase the number of under-represented minority women in surgery will require attention to recruitment, mentorship, and sponsorship.
Assuntos
Cirurgia Geral/estatística & dados numéricos , Liderança , Médicas/estatística & dados numéricos , Feminino , Previsões , Humanos , Médicas/tendências , Estados UnidosRESUMO
We present a patient with unexplained sciatica (radiating pain down the leg) found to have recurrent prostate adenocarcinoma within the sciatic nerve. High resolution MRI, especially use of an endorectal coil, improved visualization of the perineural spread of the disease. We believe that perineural spread resulting in sciatic symptoms in patients with known prostate adenocarcinoma may be an under-recognized phenomenon. The use of non-invasive modalities, high resolution endorectal coil MRI, and C-11 choline PET/CT can assist in the diagnosis of these patients.
Assuntos
Adenocarcinoma/patologia , Plexo Lombossacral/patologia , Imageamento por Ressonância Magnética/métodos , Tomografia por Emissão de Pósitrons/métodos , Neoplasias da Próstata/patologia , Nervo Isquiático/patologia , Tomografia Computadorizada por Raios X/métodos , Neoplasias Vasculares/secundário , Adenocarcinoma/diagnóstico por imagem , Idoso de 80 Anos ou mais , Biópsia , Colina , Fluordesoxiglucose F18 , Humanos , Plexo Lombossacral/diagnóstico por imagem , Masculino , Imagem Multimodal , Recidiva Local de Neoplasia , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/diagnóstico por imagem , Compostos Radiofarmacêuticos , Nervo Isquiático/diagnóstico por imagem , Neoplasias Vasculares/diagnóstico por imagemRESUMO
BACKGROUND AND OBJECTIVES: The purpose of this guideline is to update the 2010 American Academy of Neurology (AAN) brain death/death by neurologic criteria (BD/DNC) guideline for adults and the 2011 American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine guideline for infants and children and to clarify the BD/DNC determination process by integrating guidance for adults and children into a single guideline. Updates in this guideline include guidance related to conducting the BD/DNC evaluation in the context of extracorporeal membrane oxygenation, targeted temperature management, and primary infratentorial injury. METHODS: A panel of experts from multiple medical societies developed BD/DNC recommendations. Because of the lack of high-quality evidence on the subject, a novel, evidence-informed formal consensus process was used. This process relied on the panel experts' review and detailed knowledge of the literature surrounding BD/DNC to guide the development of preliminary recommendations. Recommendations were formulated and voted on, using a modified Delphi process, according to the 2017 AAN Clinical Practice Guideline Process Manual. MAJOR RECOMMENDATIONS: Eighty-five recommendations were developed on the following: (1) general principles for the BD/DNC evaluation, (2) qualifications to perform BD/DNC evaluations, (3) prerequisites for BD/DNC determination, (4) components of the BD/DNC neurologic examination, (5) apnea testing as part of the BD/DNC evaluation, (6) ancillary testing as part of the BD/DNC evaluation, and (7) special considerations for BD/DNC determination.
Assuntos
Morte Encefálica , Neurologia , Adulto , Humanos , Criança , Morte Encefálica/diagnóstico , Sociedades Médicas , Exame Neurológico , Cuidados CríticosRESUMO
The use of antibiotic-coated external ventricular catheters has been controversial among practitioners; although several papers have documented decreased adherence of microbes to catheters treated with antibiotics, there is no universally accepted practice standard for the use of coated catheters for the prevention of clinical infection. In this paper, we review the in vivo and in vitro evidence for antibiotic-coated catheters.
Assuntos
Antibioticoprofilaxia/efeitos adversos , Cateteres de Demora/efeitos adversos , Infecções Bacterianas do Sistema Nervoso Central/prevenção & controle , Viroses do Sistema Nervoso Central/prevenção & controle , Medicina Baseada em Evidências/métodos , Antibioticoprofilaxia/instrumentação , Antibioticoprofilaxia/normas , Cateteres de Demora/normas , Cateteres de Demora/tendências , Infecções Bacterianas do Sistema Nervoso Central/líquido cefalorraquidiano , Viroses do Sistema Nervoso Central/líquido cefalorraquidiano , Medicina Baseada em Evidências/tendências , Humanos , RiscoRESUMO
Disability secondary to disorders of the spine is a significant problem worldwide. In the USA, there has been a recent surge in the costs associated with caring for spinal pathology; from 1997 to 2005, there was a growth of 65% in healthcare expenditures on spinal disease, totalling $86 billion in 2005. Increasingly, there has been media and public scrutiny over the rapid rise in the volume of procedures with spinal instrumentation; some have suggested that this rise has been fuelled by non-medical drivers such as the financial incentives involved with the use of instrumentation; others suggest that innovation in spine technology and devices has led to improved options for the treatment of spine pathology.In this context, we conducted a review of the literature to assess the use of instrumentation in lumbar procedures and its relationship to successful fusion and patient outcome. Our review suggests that there is data supporting the thesis that lumbar instrumentation improves rates of fusion. However, there is no consistent correlation between increased rates of fusion and improved patient outcomes.
Assuntos
Fixadores Internos , Vértebras Lombares , Procedimentos Ortopédicos , Doenças da Coluna Vertebral/cirurgia , Humanos , Fusão Vertebral , Resultado do TratamentoRESUMO
Traditionally, neurosurgeons have responded to calls to treat new patients or address emergent, acute neurosurgical pathology in the hospitals they staff as part of their duty to the medical profession and community. Due to increasing financial pressures placed upon neurosurgical practice from hospitals and regulatory mandates, remuneration for neurosurgeon availability to serve on trauma call has become more frequent and is increasingly seen as essential. In this study, we present the first peer-review published survey of neurosurgical emergency and trauma call coverage patterns, scope, schedules, compensation, liability exposure, and call cessation. We surveyed all practicing neurosurgeon members of the American Association of Neurological Surgeons and Congress of Neurological Surgeons with a 24% response rate. The vast majority of respondents (86%), through their practice, provide 24/7/365 trauma coverage at their primary hospital site. About a third (29%) of respondents have been sued by a patient seen in the emergency department. Twenty percent of respondents anticipate retiring within the next 2 yr. Understanding trauma call coverage, remuneration, and the barriers to taking call provide needed transparency to neurosurgeons who are providing emergency, life-saving services for patients across the country. An understanding of supply and demand forces governing call coverage also assists the field in necessary workforce planning and innovation in providing access to needed, timely acute neurosurgical care.
Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Neurocirurgiões/estatística & dados numéricos , Humanos , Estados UnidosRESUMO
Operating rooms generate 42% of a hospital's revenue and 30% of hospital waste. Supply costs are 56% of a total operating room (OR) budget. US academic medical centers use 2 million pounds ($15 million) of recoverable medical supplies annually. Forming a multidisciplinary leadership team, we analyzed sources of waste focusing on our Department of Neurosurgery. We developed an 8-wk pilot project to recycle "blue wrap," the number 5 plastic polypropylene material that is ubiquitously used in ORs across the country to wrap instrument pans and implant trays for sterilization. Blue wrap can be baled and sold to recyclers where the material is pelletized and transformed into plastic products. During the 39 d of the pilot, we collected 1247 pounds of blue wrap (32 lbs collected daily). The cost of the pilot was $14 987 that includes a new baler ($11 200) and 5 transport carts ($3697). The revenue received from baled blue wrap was 8 cents per pound. Cost avoidance yielded $31 680.00 in savings. Implementation of this pilot across our main hospital would yield $5000 in revenue annually and $174 240 in cost avoidance. This project can be replicated at other centers and not only reduces the environmental footprint, but also helps generate additional revenue by recycling a necessary packing material that would otherwise require payment for disposal.
Assuntos
Salas Cirúrgicas , Reciclagem/economia , Reciclagem/métodos , Gerenciamento de Resíduos/economia , Gerenciamento de Resíduos/métodos , Centros Médicos Acadêmicos , Humanos , Projetos Piloto , PolipropilenosRESUMO
The hippocampus is especially sensitive to the effects of gestational and neonatal iron deficiency, even after iron repletion. This study compared the effects of iron deficiency, maintained from gestational day 2 to postnatal day (P)7, on "delay" and "trace" fear conditioning. Only the latter paradigm is critically dependent on the dorsal hippocampus. In different groups of rats, fear conditioning commenced either prior to puberty (P28 or P35) or after puberty (P56). Fear conditioning was measured using fear-potentiated startle. Both delay and trace fear conditioning were diminished by iron deficiency at P28 and P35. Hippocampal expression of the plasticity-related protein PKC-gamma was increased through trace fear conditioning, but reduced at P35 in the iron-deficient group. Trace fear conditioning was enhanced by prior iron deficiency in the P56 group. This unanticipated finding in iron-repleted adults is consistent with the effects of developmental iron deficiency on inhibitory avoidance learning, but contrasts with the persistent deleterious long-term effects of a more severe iron-deficiency protocol, suggesting that degree and duration of iron deficiency affects the possibility of recovery from its deleterious effects.
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Envelhecimento , Anemia Ferropriva/fisiopatologia , Condicionamento Clássico/fisiologia , Medo , Fenômenos Fisiológicos da Nutrição Pré-Natal , Fatores Etários , Análise de Variância , Animais , Comportamento Animal , Feminino , Hipocampo/enzimologia , Ferro da Dieta/administração & dosagem , Masculino , Gravidez , Proteína Quinase C/metabolismo , Ratos , Ratos Sprague-Dawley , Reflexo de Sobressalto/fisiologiaRESUMO
Assuring clinical competence throughout the career of a neurosurgeon is of paramount importance for patient safety. We present the first comprehensive survey of all neurosurgeons board certified through the American Board of Neurological Surgery (ABNS) to evaluate perceptions of Maintenance of Certification (MOC). We administered a validated, online, confidential survey to 4899 neurosurgeons (2435 ABNS diplomates participating in MOC, 1440 diplomates certified prior to 1999 [time-unlimited certificates], and 1024 retired diplomates). We received 1449 responses overall (30% response rate). Our study found that most respondents believe that neurosurgeons should be required to participate in continuing professional improvement following initial board certification (75%). Most believe that specialty boards, working in conjunction with specialty societies, should require diplomates to participate in programs meant to promote continuous professional development (73%). The majority of respondents (76%) believed that self-assessment tests constituted a meaningful professional development activity, in addition to periodic case log reviews (33%) or quality improvement projects (32.6%). A plurality of respondents (44%) do not feel that the MOC process as currently structured provides them with value. There were no differences between those who were "grandfathered" and those who actively participate in MOC and no differences between those in private practice versus those in academics. The ABNS is cognizant of diplomate concerns and is actively developing new MOC paradigms to ensure that the process achieves both the goals of meeting the public interest and assuring that the quality of American neurosurgery remains exemplary.
Assuntos
Atitude do Pessoal de Saúde , Certificação/normas , Competência Clínica/normas , Neurocirurgiões/psicologia , Neurocirurgiões/normas , Inquéritos e Questionários/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Educação Médica Continuada/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neurocirurgia/educação , Neurocirurgia/normas , Segurança do Paciente/normas , Melhoria de Qualidade/normas , Autoavaliação (Psicologia) , Conselhos de Especialidade Profissional/normas , Fatores de Tempo , Estados UnidosRESUMO
Vehicles for life-long assessment such as Maintenance of Certification tend to focus on generalist neurosurgical knowledge. However, as neurosurgeons advance in their careers, they tend to narrow their practice and increase volumes in certain specific types of operations. Failing to test the type of procedures most relevant to the practitioner is a lost opportunity to improve the knowledge and practice of the individual neurosurgeon. In this study, we assess the neurosurgical community's appetite for designations of board-recognized Recognized Focused Practice (RFP). We administered a validated, online, confidential survey to 4,899 neurosurgeons (2,435 American Board of Neurological Surgery (ABNS) Diplomates participating in MOC, 1,440 Diplomates certified prior to 1999 (grandfathered), and 1,024 retired Diplomates). We received 1,449 responses overall (30% response rate). A plurality of respondents were in practice 11-15 years (18.5%), in private practice (40%) and participate in MOC (61%). 49% of respondents felt that a RFP designation would not be helpful. For the 30% who felt that RFP would be helpful, 61.3% felt that it would support recognition by their hospital or practice, it would motivate them to stay current on medical knowledge (53.4%), or it would help attract patients (46.4%;). The most popular suggestions for RFP were Spine (56.2%), Cerebrovascular (62.9%), Pediatrics (64.1%), and Functional/Stereotactic (52%). A plurality of neurosurgeons (35.7%) felt that RFP should recognize neurosurgeons with accredited and non-accredited fellowship experience and sub-specialty experience. Ultimately, Recognized Focused Practice may provide value to individual neurosurgeons, but the neurosurgical community shows tepid interest for pursuing this designation.
Assuntos
Neurocirurgiões , Adulto , Idoso de 80 Anos ou mais , Humanos , Pessoa de Meia-Idade , Estados UnidosRESUMO
OBJECTIVE: To present the first wide-scale survey to assess perceptions of testing the aging neurosurgeon. PATIENTS AND METHODS: This study included 4899 neurosurgeons, 2435 American Board of Neurological Surgery Diplomates participating in Maintenance of Certification (MOC), 1440 Diplomates certified before 1999 (grandfathered), and 1024 retired Diplomates. We developed an online confidential survey conducted from March 1, 2016, to May 31, 2016. We received 1449 responses overall (30% response rate). RESULTS: Most respondents (938; 65%) were aged 50 years and older. Overall, most respondents (718; 50%) believe that the aging neurosurgeon (65 years and older) should undergo additional testing, including cognitive assessment or a review of cases, in addition to a standard (MOC) examination. Nine hundred fifty-six (67%) respondents believed that there should be no absolute age cutoff at which neurosurgical practice is forced to end. Six hundred six (42%) respondents believed that MOC should be tailored to accommodate the aging neurosurgeon. Most respondents (766; 59%) believed that MOC should consist of a review individual case logs and patient outcomes for the aging neurosurgeon. CONCLUSION: Appropriately assessing the aging neurosurgeon is important to protect patient safety and also maximize the capacity of an aging neurosurgical workforce. This first of its kind survey of neurosurgeon diplomates of the American Board of Neurological Surgery provides important information as to what mechanisms can be created to fairly evaluate aging neurosurgeons. Although this is a study of neurosurgeons, the implications of these findings are widely applicable across specialties, and additional research on testing for aging and competency is needed across specialties.
Assuntos
Certificação/normas , Competência Clínica/normas , Competência Mental/normas , Neurocirurgia/normas , Fatores Etários , Idoso , Atitude do Pessoal de Saúde , Esgotamento Profissional/prevenção & controle , Feminino , Humanos , Masculino , Inquéritos e Questionários , Estados UnidosRESUMO
BACKGROUND: The Open Payments Database (OPD) was launched by the Centers for Medicare & Medicaid Services in 2014. Through this online searchable database, the public can explore physician-industry interactions. To date, there is no published literature on the accuracy of the database for neurosurgeons or any physician specialty. OBJECTIVE: To study the accuracy of published records and scope of industry-neurosurgeon relationships between neurosurgeons and industry within the OPD. METHODS: We searched 4.3 million records in 2013 and 11.41 million records in 2014 in the OPD for board-certified neurosurgeons verified by the American Board of Neurological Surgery. Delimit software was used to condense these data, Microsoft Access for database queries, and STATA to perform descriptive analyses. RESULTS: Of the 3240 neurosurgeons in the OPD in 2013, 2020 were identified correctly as neurosurgeons within the database (62%). Of the 3593 neurosurgeons in the OPD in 2014, 2433 were identified correctly as neurosurgeons (68%). Within the OPD in 2013, there were 72 066 attributed records for neurosurgeons; within the 2014 OPD, there were 160â 563 attributed records for neurosurgeons. Total payments to neurosurgeons in 2013 (for the 9 months published in OPD): $61 â802 â659.37; in 2014: $117 â127 â824.00. CONCLUSION: The OPD details physician interactions with industry and has multiple inaccuracies. Publicly availing inaccurate information through a searchable governmental website that can be accessed by patients and journalists alike has the potential to tarnish individual neurosurgeons and undermine professional credibility. ABBREVIATIONS: CMS, Centers for Medicare & Medicaid ServicesOPD, Open Payments Database.
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Bases de Dados Factuais , Reembolso de Seguro de Saúde , Neurocirurgia , Humanos , Medicaid , Medicare , Estados UnidosRESUMO
OBJECT Recent studies have examined the impact of perceived medicolegal risk and compared how this perception impacts defensive practices within the US. To date, there have been no published data on the practice of defensive medicine among neurosurgeons in Canada. METHODS An online survey containing 44 questions was sent to 170 Canadian neurosurgeons and used to measure Canadian neurosurgeons' perception of liability risk and their practice of defensive medicine. The survey included questions on the following domains: surgeon demographics, patient characteristics, type of physician practice, surgeon liability profile, policy coverage, defensive behaviors, and perception of the liability environment. Survey responses were analyzed and summarized using counts and percentages. RESULTS A total of 75 neurosurgeons completed the survey, achieving an overall response rate of 44.1%. Over one-third (36.5%) of Canadian neurosurgeons paid less than $5000 for insurance annually. The majority (87%) of Canadian neurosurgeons felt confident with their insurance coverage, and 60% reported that they rarely felt the need to practice defensive medicine. The majority of the respondents reported that the perceived medicolegal risk environment has no bearing on their preferred practice location. Only 1 in 5 respondent Canadian neurosurgeons (21.8%) reported viewing patients as a potential lawsuit. Only 4.9% of respondents would have selected a different career based on current medicolegal risk factors, and only 4.1% view the cost of annual malpractice insurance as a major burden. CONCLUSIONS Canadian neurosurgeons perceive their medicolegal risk environment as more favorable and their patients as less likely to sue than their counterparts in the US do. Overall, Canadian neurosurgeons engage in fewer defensive medical behaviors than previously reported in the US.
Assuntos
Atitude do Pessoal de Saúde , Medicina Defensiva , Neurocirurgia , Adulto , Idoso , Canadá , Comparação Transcultural , Feminino , Humanos , Masculino , Imperícia , Pessoa de Meia-Idade , Risco , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Defensive medicine is prevalent among US neurosurgeons due to the high risk of malpractice claims. This study provides national estimates of US neurosurgeons' defensive behaviors and perceptions. OBJECTIVE: To examine the relationship of defensive medicine-both "assurance" behaviors and "avoidance" behaviors-to the liability environment. METHODS: A 51-question online survey was sent to 3344 US neurosurgeon members of the American Board of Neurological Surgeons (ABNS). The survey was anonymous and conducted over 6 weeks in the spring of 2011. The previously validated questionnaire contained questions on neurosurgeon, patient, and practice characteristics; perceptions of the liability environment; and defensive-medicine behaviors. Bivariate and multivariate analyses examined the state liability risk environment as a predictor of a neurosurgeon's likelihood of practicing defensive medicine. RESULTS: A total of 1026 neurosurgeons completed the survey (31% response rate). Neurosurgeons' perceptions of their state's liability environment generally corresponded well to more objective measures of state-level liability risk because 83% of respondents correctly identified that they were practicing in a high-risk environment. When controlling for surgeon experience, income, high-risk patient load, liability history, and type of patient insurance, neurosurgeons were 50% more likely to practice defensive medicine in high-risk states compared with low-risk-risk states (odds ratio: 1.5, P<.05). CONCLUSION: Both avoidance and assurance behaviors are prevalent among US neurosurgeons and are correlated with subjective and objective measures of state-level liability risk. Defensive medicine practices do not align with patient-centered care and may contribute to increased inefficiency in an already taxed health care system.