Clinical and Operative Risk Factors Associated With Prolonged Length of Stay After Endoscopic Pituitary Adenoma Resection.

BACKGROUND AND OBJECTIVES: Pituitary adenomas (PAs) are the most common intrasellar tumor. Clinically relevant adenomas have a prevalence of 1 per 1000 in the general population. Transsphenoidal surgery (TSS) is the most common surgical treatment and is the first-line management for most PAs. Most patients fare well postoperatively, but a subset of patients experience a prolonged length of stay (PLOS). In this article, we aim to identify demographic and clinical factors associated with PLOS after TSS for PA. METHODS: Patients with sellar pathologies surgically treated at a single tertiary center from March 1, 2009, to May 31, 2020, were retrospectively reviewed. All patients older than 18 years receiving nonemergent endoscopic TSS for pituitary adenoma were included. Clinical and demographic characteristics were analyzed using χ 2 -tests and student t -tests. For those factors with a P -value less than .01, multivariate logistic regression and negative binomial regression models were constructed to estimate the adjusted odds of PLOS across predictive factors. RESULTS: A total of 301 patients were included in the study. This cohort had an average age of 54.65 ± 15.06 years and an average body mass index of 29.47 ± 6.69. The median length of stay was 54.9 hours [25th-75th percentiles: 43.5-72.9]. Postoperative cerebrospinal fluid leak ( P < .01), postoperative diabetes insipidus (DI) ( P < .01), increased surgery duration ( P = .01), and elevated maximal tumor dimension ( P = .01) were predictive of PLOS in logistic regression. Increased surgery duration, previous pituitary radiation, intraoperative complications, and postoperative DI (all P < .01) were associated with increased rate of PLOS in negative binomial regression. CONCLUSION: Patients undergoing endoscopic TSS for PA resection demonstrate prolonged lengths of stay if they have higher tumor burden, have lengthier surgeries with intraoperative complications, or develop postoperative complications such as cerebrospinal fluid leak or DI. Careful monitoring of these factors will allow for better resource optimization, reducing costs to both the hospital and the patient.

Development of a novel instrument to characterize telemedicine programs in primary care.

BACKGROUND: Given the rapid deployment of telemedicine at the onset of the COVID - 19 pandemic, updated assessment methods are needed to study and characterize telemedicine programs. We developed a novel semi - structured survey instrument to systematically describe the characteristics and implementation processes of telemedicine programs in primary care. METHODS: In the context of a larger study aiming to describe telemedicine programs in primary care, a survey was developed in 3 iterative steps: 1) literature review to obtain a list of telemedicine features, facilitators, and barriers; 2) application of three evaluation frameworks; and 3) stakeholder engagement through a 2-stage feedback process. During survey refinement, items were tested against the evaluation frameworks while ensuring it could be completed within 20-25 min. Data reduction techniques were applied to explore opportunity for condensed variables/items. RESULTS: Sixty initially identified telemedicine features were reduced to 32 items / questions after stakeholder feedback. Per the life cycle framework, respondents are asked to report a month in which their telemedicine program reached a steady state, i.e., "maturation". Subsequent questions on telemedicine features are then stratified by telemedicine services offered at the pandemic onset and the reported point of maturation. Several open - ended questions allow for additional telemedicine experiences to be captured. Data reduction techniques revealed no indication for data reduction. CONCLUSION: This 32-item semi-structured survey standardizes the description of primary care telemedicine programs in terms of features as well as maturation process. This tool will facilitate evaluation of and comparisons between telemedicine programs across the United States, particularly those that were deployed at the pandemic onset.

The Telemedicine Experience in Primary Care Practices in the United States: Insights From Practice Leaders.

PURPOSE: The need to rapidly implement telemedicine in primary care during the coronavirus disease 2019 (COVID-19) pandemic was addressed differently by various practices. Using qualitative data from semistructured interviews with primary care practice leaders, we aimed to report commonly shared experiences and unique perspectives regarding telemedicine implementation and evolution/maturation since March 2020. METHODS: We administered a semistructured, 25-minute, virtual interview with 25 primary care practice leaders from 2 health systems in 2 states (New York and Florida) included in PCORnet, the Patient-Centered Outcomes Research Institute clinical research network. Questions were guided by 3 frameworks (health information technology evaluation, access to care, and health information technology life cycle) and involved practice leaders' perspectives on the process of telemedicine implementation in their practice, with a specific focus on the process of maturation and facilitators/barriers. Two researchers conducted inductive coding of qualitative data open-ended questions to identify common themes. Transcripts were electronically generated by virtual platform software. RESULTS: Twenty-five interviews were administered for practice leaders representing 87 primary care practices in 2 states. We identified the following 4 major themes: (1) the ease of telemedicine adoption depended on both patients' and clinicians' prior experience using virtual health platforms, (2) regulation of telemedicine varied across states and differentially affected the rollout processes, (3) visit triage rules were unclear, and (4) there were positive and negative effects of telemedicine on clinicians and patients. CONCLUSIONS: Practice leaders identified several challenges to telemedicine implementation and highlighted 2 areas, including telemedicine visit triage guidelines and telemedicine-specific staffing and scheduling protocols, for improvement.

Inconsistent Surgical Implant Documentation: A Case Study in Total Knee and Hip Arthroplasty.

Value-based care initiatives require accurate quantification of resource utilization. This study explores hospital resource documentation performance for total knee and hip arthroplasty (TKA, THA) implants and how this may differ between hospitals. This retrospective study utilized the Premier discharge database, years 2006 to 2020. TKA/THA cases were categorized into 5 tiers based upon the completeness of implant component documentation: Platinum, Gold, Silver, Bronze, Poor. Correlation between TKA and THA documentation performance (per-hospital percentage of Platinum cases) was assessed. Logistic regression analyses measured the association between hospital characteristics (region, teaching status, bed size, urban/rural) and satisfactory documentation. TKA/THA implant documentation performance was compared to documentation for endovascular stent procedures. Individual hospitals tended to have very complete (Platinum) or very incomplete (Poor) documentation for both TKA and THA. TKA and THA documentation performance were correlated (correlation coefficient = .70). Teaching hospitals were less likely to have satisfactory documentation for both TKA (P = .002) and THA (P = .029). Documentation for endovascular stent procedures was superior compared to TKA/THA. Hospitals' TKA and THA-related implant documentation performance is generally either very proficient or very poor, in contrast with often well-documented endovascular stent procedures. Hospital characteristics, other than teaching status, do not appear to impact TKA/THA documentation completeness.

Comparison of Frailty Indices and the Charlson Comorbidity Index in Traumatic Brain Injury.

BACKGROUND: Comorbidity scales for outcome prediction in traumatic brain injury (TBI) include the 5-component modified Frailty Index (mFI-5), the 11-component modified Frailty Index (mFI-11), and the Charlson Comorbidity Index (CCI). OBJECTIVE: To compare the accuracy in predicting clinical outcomes in TBI of mFI-5, mFI-11, and CCI. METHODS: The National Trauma Data Bank (NTDB) of the American College of Surgeons (ACS) was utilized to study patients with isolated TBI for the years of 2017 and 2018. After controlling for age and injury severity, individual multivariable logistic regressions were conducted with each of the 3 scales (mFI-5, mFI-11, and CCI) against predefined outcomes, including any complication, home discharge, facility discharge, and mortality. RESULTS: All 3 scales demonstrated adequate internal consistency throughout their individual components (0.63 for mFI-5, 0.60 for CCI, and 0.56 for mFI-11). Almost all studied complications were significantly more likely in frail patients. mFI-5 and mFI-11 had similar areas under the curve (AUC) for all outcomes, while CCI had lower AUCs (0.62-0.61-0.53 for any complication, 0.72-0.72-0.52 for home discharge, 0.78-0.78-0.53 for facility discharge, and 0.71-0.70-0.52 for mortality, respectively). CONCLUSION: mFI-5 and mFI-11 demonstrated similar accuracy in predicting any complication, home discharge, facility discharge, and mortality in TBI patients across the NTDB. In addition, CCI's performance was poor for the aforementioned metrics. Since mFI-5 is simpler, yet as accurate as the 2 other scales, it may be the most practical both for clinical practice and for future studies with the NTDB.

Musculoskeletal Telemedicine Trends Preceding the COVID-19 Pandemic and Potential Implications of Rapid Telemedicine Expansion.

Introduction: Telemedicine was rapidly deployed at the onset of the COVID-19 pandemic. Little has been published on telemedicine in musculoskeletal care prior to the COVID-19 pandemic. This study is aimed at characterizing trends in telemedicine for musculoskeletal care preceding the COVID-19 pandemic. Methods: This retrospective study used insurance claims from the Truven MarketScan database. Musculoskeletal-specific outpatient visits from 2014 to 2018 were identified using the musculoskeletal major diagnostic category ICD-10 codes. Telemedicine visits were categorized using CPT codes and Healthcare Common Procedure Coding Systems. We described annual trends in telemedicine in the overall dataset and by diagnosis grouping. Multivariable logistic regression modeling estimated the association between patient-specific and telemedicine visit variables and telemedicine utilization. Results: There were 36,672 musculoskeletal-specific telemedicine visits identified (0.020% of all musculoskeletal visits). Overall, telemedicine utilization increased over the study period (0% in 2014 to 0.05% in 2018). Orthopedic surgeons had fewer telemedicine visits than primary care providers (OR 0.57, 95% CI 0.55-0.59). The proportion of unique patients utilizing telemedicine in 2018 was higher in the south (OR 2.28, 95% CI 2.19-2.38) and west (OR 5.58, 95% CI 5.36-5.81) compared to the northeast. Those with increased comorbidities and lower incomes and living in rural areas had lower rates of telemedicine utilization. Conclusions: From 2014 to 2018, there was an increase in telemedicine utilization for musculoskeletal visits, in part due to insurance reimbursement and telemedicine regulation. Despite this increase, the rates of telemedicine utilization are still lowest in some of the groups that could derive the most benefit from these services. Establishing this baseline is important for assessing how the roll-out of telemedicine during the pandemic impacted how/which patients and providers are utilizing telemedicine today.

Gender Differences in Iliofemoral Vein Stenting for Chronic Venous Insufficiency.

INTRODUCTION: Little is known about gender's role in chronic venous insufficiency (CVI). The aim of this study was to evaluate the impact of gender on outcomes of iliac vein stenting(IVS) for CVI. METHODS: 866 patients who underwent vein stenting for CVI at one institution from August 2011 to June 2021 were analyzed via retrospective review. Patients were followed up to 5 years after initial stent placement. Presenting symptoms were quantified using Venous Clinical Severity Score(VCSS), Clinical Assessment Score(CAS), and Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) class. Reoperations after initial IVS were recorded. Major reoperations were defined as iliac interventions using venography. Minor reoperations were defined as thermal ablation. Multivariate logistic regression models were used determine odds of any and major reintervention. RESULTS: Compared to females, males pre-operatively presented with a higher mean CEAP class (3.6 vs .3.3; P < .001), VCSS composite (11.3 vs .9.9; P < .001), and smoking history (134 vs .49; P < .001). The 2 groups were similar in age (P = .125), BMI(P = .898), previous DVT (P = .085), diabetes (P = .386), hypertension (P = 1.0), and CAD (P = .499). Multivariate analyses revealed no association between gender and any reintervention (OR, 1.02; 95%CI, .71-1.46; P = .935) or gender and major reintervention (OR, 1.39; 95% CI, .86-2.23 P = .177). There were no differences in number of stents placed (P = .736) or symptomatic improvement at 1 month (P = .951), 3 months (P = .233), 6 months(P = .068), and greater than 1 year (P = .287). At the 1 year follow-up, the male cohort had higher CAS values than females P = .034). Males had larger reduction in composite VCSS than women at 1 year (5.1 vs. 3.8; P = .003) and 3 years (5.3 vs .3.7; P = .031) of follow-up and similar levels of improvement in post-op (4.0 vs .3.5; P = .059), 2 years (4.3 vs .3.8; P = .295), 4-years (5.1 vs .4.6; P = .529), 5 years (5.6 vs .4.2; P = .174), and 6 years (5.93vs.3.3 P = .089). CONCLUSIONS: In a single site study of IVS in patients with CVI, males tended to present worse symptoms than females. After surgery, however, both cohorts showed improvement, and both seemed to improve to the same degree of residual symptoms.

High Thoracic Tortuosity Is Associated With CT-Markers of Degeneration of the Descending Thoracic Aortic Wall.

OBJECTIVE/INTRODUCTION: Increased vascular tortuosity may be an independent marker of generalized aortic pathology. This study investigates the association between descending thoracic aortic tortuosity, aneurysm pathophysiology, and outcomes following EVAR in AAA patients. METHODS: Patients who underwent elective EVAR between 2004 and 2018 were reviewed. Thoracic tortuosity index (TTI) was measured using 3D reconstruction software. Patients were dichotomized across the median TTI into high tortuosity [HT] (TTI >1.27, Figure1(a)) and low tortuosity [LT] (TTI ≤1.27, Figure 1(b)) groups. Perioperative complications, postoperative outcomes, and CT-based features of thoracic aortic wall degeneration (Figure 1(c)-(e)) were collected and analyzed. RESULTS: 136 patients underwent treatment: 70 HT patients, including 54 males and 16 females (mean age: 77 years), and 66 LT patients, including 62 males and 4 females (mean age: 70 years) (age; P < .001). LT patients exhibited greater prevalence of hypercholesterolemia and diabetes (P = .045, P = .01). Presence of degenerative aortic wall markers was greater in HT patients (P = .045). HT patients had higher incidence of multiple aneurysms concurrently present in their aorta compared to LT (32.8% vs 11.3%; P = .002). Frequency of AAA rupture/dissection was 4.3% for HT and 1.5% for LT (P = .339). A trend was observed in all cause 30-day mortality in the HT group (P = .061). Other perioperative complications and postoperative outcomes were similar between groups. CONCLUSION: High TTI was associated with older age at time of EVAR, greater prevalence of degenerative markers in the descending thoracic aortic wall, and widespread aorto-iliac dilation. While not predictive of EVAR outcomes, TTI can provide valuable information regarding aneurysm pathophysiology.

Sentiment Analysis of Online Patient-Written Reviews of Vascular Surgeons.

BACKGROUND: Online patient reviews influence a patient's choice of a vascular surgeon. The aim of this study is to examine underlying factors that contribute to positive and negative patient reviews by leveraging sentiment analysis and machine learning methods. METHODS: The Society of Vascular Surgeons publicly accessible member directory was queried and cross-referenced with a popular patient-maintained physician review website, healthgrades.com. Sentiment analysis and machine learning methods were used to analyze several parameters. Demographics (gender, age, and state of practice), star rating (of 5 stars), and written reviews were obtained for corresponding vascular surgeons. A sentiment analysis model was applied to patient-written reviews and validated against the star ratings. Student's t-test or one-way analysis of variance assessed demographic relationships with reviews. Word frequency assessments and multivariable logistic regression analyses were conducted to identify common and determinative components of written reviews. RESULTS: A total of 1,799 vascular surgeons had public profiles with reviews. Female gender of surgeon was associated with lower star ratings (male = 4.19, female = 3.95, P < 0.01) and average sentiment score (male = 0.50, female = 0.40, P < 0.01). Younger physician age was associated with higher star rating (P = 0.02) but not average sentiment score (P = 0.12). In the Best reviews, the most commonly used one-words were Care (N = 999), Caring (N = 767), and Kind (N = 479), while the most commonly used two-word pairs were Saved/Life (N = 189), Feel/Comfortable (N = 106), and Kind/Caring (N = 104). For the Worst reviews, the most commonly used one-words were Pain (N = 254) and Rude (N = 148), while the most commonly used two-word pairs were No/One (N = 27), Waste/Time (N = 25), and Severe/Pain (N = 18). In a multiple logistic regression, satisfactory reviews were associated with words such as Confident (odds ratio [OR] = 8.93), Pain-free (OR = 4.72), Listens (OR = 2.55), and Bedside Manner (OR = 1.70), while unsatisfactory reviews were associated with words such as Rude (OR = 0.01), Arrogant (OR = 0.09), Infection (OR = 0.20), and Wait (OR = 0.48). CONCLUSIONS: Female surgeons received significantly worse reviews and younger surgeons tended to receive better reviews. The positivity and negativity of reviews were largely related to words associated with the patient-doctor experience and pain. Vascular surgeons should focus on these 2 areas to improve patient experiences and their own reviews.

Race differences in iliofemoral vein stenting for chronic venous insufficiency.

INTRODUCTION: Major disparities in outcomes by race are present throughout vascular surgery, yet little has been published on iliac vein stent outcomes by race. This retrospective study assessed iliac vein stent outcomes by patient race. METHODS: Patients who underwent iliac vein stenting at a single institution for chronic venous insufficiency (CVI) from 2011 to 2021 were reviewed. Demographic, preoperative, perioperative, and postoperative data were collected. Self-reported race groups included Asian, Black, Hispanic, and White. Univariate differences were analyzed using χ2 tests for categorical variables and 1-way ANOVA for continuous variables. Outcomes included change in Venous Clinical Severity Score (VCSS) at interval timepoints relative to a preoperative baseline and reinterventions. Logistic regression models were used to determine the unadjusted and adjusted odds ratio (OR) of any minor and major reintervention. Multivariate regression models controlled for demographic and comorbidity characteristics. RESULTS: A total of 827 patients were included. Asian patients were younger and had a greater proportion of male patients, lower Body mass index (BMI), less smoking history, and fewer comorbidities. White patients were more likely to have a history of deep vein thrombosis (DVT). White patients presented with the most severe CVI symptoms as defined by both Clinical-Etiological-Anatomical-Pathophysiological (CEAP) classification and preoperative VCSS composite scores. There were no differences in acute DVT, number of stents deployed, and bilateral versus unilateral stent placement. Black patients had the longest average days of follow-up, followed sequentially by Hispanic, White, and Asian. Black patients had the most reinterventions, while Asian patients had the fewest. Asian patients were less likely to have a major reintervention. No differences in VCSS composite or change in VCSS were observed. CONCLUSIONS: In patients with CVI, Asian patients presented younger and healthier, while White patients presented with the most severe symptoms. No differences were observed in VCSS outcomes, though Black patients had the most reinterventions.

Iliac vein stenting outcomes for patients with superficial venous insufficiency concurrent with deep venous disease.

OBJECTIVE: Many patients will present with chronic proximal venous outflow obstruction (PVOO) and superficial venous insufficiency (SVI) at the time of iliac vein stenting. In the present study, we aimed to determine whether differences in outcomes were present for patients receiving an iliac vein stent according to whether concurrent SVI was present. METHODS: A registry of 553 patients who had undergone iliac vein stent placement for chronic PVOO from 2011 to 2021 was retrospectively analyzed. Two groups of patients were followed for ≤6 years after initial vein stent placement: group 1 (n = 178; 32.2%) had not had SVI before or after stent placement and group 2 (n = 375; 67.8%) had had SVI at initial iliac vein stent procedure. The patients' symptoms were evaluated using the venous clinical severity score (VCSS). Postoperative procedures after initial stent placement were recorded. Postoperative procedures included any operation performed after the index iliac vein stent procedure. Endovenous thermal ablation was classified as a minor postoperative procedure, and any intervention with venography was classified as a major postoperative reintervention. Multivariate regression models were used to determine the odds of a major reintervention or minor procedure postoperatively. RESULTS: Across the two groups, the mean age (group 1, 65.3 years; group 2, 59.9 years; P < .001), body mass index (27.6 vs 26.1 kg/m2; P = .004), diabetes (32.6% vs 17.6%; P < .001), arterial hypertension (68.5% vs 42.1%; P < .001), and coronary artery disease (16.9% vs 9.6%; P = .048) differed significantly. The time to follow-up was similar between the two groups (P = .915). Longitudinally, both groups had had similar improvements in the composite VCSSs. After multivariable adjustment, group 2 was more likely than group 1 (odds ratio, 5.26; 95% confidence interval, 3.33-8.59; P < .001) to have required a postoperative minor procedure, but not a major reintervention. Group 2 had also averaged a shorter interval from the index procedure to a postoperative procedure than group 1 (525.7 days vs 258.1 days; P < .001). CONCLUSIONS: Compared with patients without SVI, those with SVI and chronic PVOO were younger, had had fewer comorbidities, and fared similarly in the change in the composite VCSSs but were more likely to have required a minor procedure and less likely to have required a major reintervention after the index iliac vein stent procedure.

Patients with active venous leg ulcers at the time of iliac vein stenting require more reoperations.

OBJECTIVE: An active venous leg ulcer (VLU) caused by lower extremity venous insufficiency is challenging to treat and will often recur after initially healing. In the present study, we compared the symptomatic outcomes and need for reoperation after iliac vein stenting (IVS) in patients with an active VLU (VLU+) and those without an active VLU (VLU-). METHODS: A single-institution database of patients with chronic venous outflow obstruction who underwent IVS from August 2011 to June 2021 was analyzed. Symptoms were quantified using the venous clinical severity score. The patients were divided into two cohorts: those with (VLU+) and without (VLU-) VLUs. RESULTS: A total of 872 patients (71 VLU+ and 801 VLU-) were identified. Many of the demographics and comorbidities differed between the two cohorts, and these variables were included in the multivariable analysis. On univariate analysis, the VLU+ cohort was more likely to need a major reoperation (odds ratio, 1.94; 95% confidence interval, 1.01-3.52; P = .036). However, on multivariable analysis, the difference was not statistically significant (odds ratio, 1.17; 95% confidence interval, 0.55-2.40; P = .667). Additionally, the VLU+ cohort required a significantly greater mean total of reoperations (1.4 vs 1.0; P = .006) than the VLU- cohort. Comparatively, for patients who underwent at least one reoperation, the difference in the mean total number of reoperations was even greater for the VLU+ cohort (2.6 vs 1.8; P = .001). The results from the Kaplan-Meier log-rank test revealed no differences in the reintervention-free survival time (P = .980). Both cohorts experienced a durable mean reduction in the venous clinical severity score. The ulcer healing rates for the VLU+ cohort at 6, 12, 24, and 36 months were 38%, 47%, 52%, and 59%, respectively. The ulcer recurrence rates for the VLU+ cohort were 4%, 10%, 19%, and 30% at 6, 12, 24, and 36 months, respectively, with a median time to recurrence of 1.2 years. CONCLUSIONS: Patients with active VLUs who underwent a first reintervention after initial IVS, on average, required an additional reintervention.

Symptom Relief and Reintervention after Iliac Vein Stenting Stratified by CEAP Clinical Classification.

BACKGROUND: This study sought to evaluate long-term symptom relief and reintervention rates after iliac vein stenting (IVS) in patients with chronic venous outflow obstruction. METHODS: A single-institution database of patients undergoing IVS from August 2011 to June 2021 was analyzed. Patients were stratified into three cohorts based on the clinical component of the clinical, etiology, anatomical, and pathophysiology (CEAP) classification: C3, C4, and C5/6. Symptoms were quantified using the venous clinical severity score (VCSS). Reintervention was defined as any procedure using venography. Edema, pigmentation, and ulceration progression-free survival as well as reintervention-free survival were assessed with Kaplan Meier analysis. RESULTS: Among 737 total patients, there were 435 C3, 206 C4, and 96 C5/6 patients. The C5/6 cohort had the highest percentage of patients undergo reoperation (36.4%). C5/6 patients yielded the poorest ulceration progression-free survival (P < 0.001) while C3 patients had the poorest skin pigmentation progression-free survival (P = 0.009). On adjusted analysis there was no significant difference in odds of reintervention between study cohorts. Mean composite VCSS scores were significantly different at each yearly post-operative follow-up visit up to 6 years. CONCLUSIONS: The present study is one of the largest investigations of long-term outcomes in IVS patients. Most patients with long-term follow-up experienced an improvement in their composite VCSS. CEAP clinical classification at the time of IVS had a significant influence on the likelihood and quantity of reintervention.

Delayed Cranial Decompression Rates After Initiation of Unfractionated Heparin versus Low-Molecular-Weight Heparin in Traumatic Brain Injury.

BACKGROUND: Both unfractionated heparin (UH) and low-molecular-weight heparin (LMWH) are routinely used prophylactically after traumatic brain injury (TBI) to prevent deep vein thrombosis (DVT). Their comparative risk for development or worsening of intracranial hemorrhage necessitating cranial decompression is unclear. Furthermore, the absence of a specific antidote for LMWH may lead to UH being used more often for high-risk patients. This study aims to compare the incidence of delayed cranial decompression occurring after initiation of prophylactic UH versus LMWH using the National Trauma Data Bank. METHODS: Cranial decompression procedures included craniotomy and craniectomy. Multiple imputation was used for missing data. Propensity score matching was used to account for selection bias between UH and LMWH. The 1:1 matched groups were compared using logistic regression for the primary outcome of postprophylaxis cranial decompression. RESULTS: A total of 218,594 patients with TBI were included, with 61,998 (28.3%) receiving UH and 156,596 (71.7%) receiving LMWH as DVT prophylaxis. The UH group had higher patient age, body mass index, comorbidity rates, Injury Severity Score, and worse motor Glasgow Coma Scale score. After the UH and LMWH groups were matched for these factors, logistic regression showed lower rates of postprophylaxis cranial decompression for the LMWH group (odds ratio, 0.13; 95% confidence interval, 0.11-0.16; P < 0.001). CONCLUSIONS: Despite the absence of a specific antidote, LMWH was associated with lower rates of need for post-DVT-prophylaxis in craniotomy/craniectomy. This finding questions the notion of UH being safer for patients with TBI because it can be readily reversed. Randomized studies are needed to elucidate causality.

Neurosurgical Performance in the First 2 Years of Merit-Based Incentive Payment System: A Descriptive Analysis and Predictors of Receiving Bonus Payments.

BACKGROUND: The merit-based incentive payment system (MIPS) program was implemented to tie Medicare reimbursements to value-based care measures. Neurosurgical performance in MIPS has not yet been described. OBJECTIVE: To characterize neurosurgical performance in the first 2 years of MIPS. METHODS: Publicly available data regarding MIPS performance for neurosurgeons in 2017 and 2018 were queried. Descriptive statistics about physician characteristics, MIPS performance, and ensuing payment adjustments were performed, and predictors of bonus payments were identified. RESULTS: There were 2811 physicians included in 2017 and 3147 in 2018. Median total MIPS scores (99.1 vs 90.4, P < .001) and quality scores (97.9 vs 88.5, P < .001) were higher in 2018 than in 2017. More neurosurgeons (2758, 87.6%) received bonus payments in 2018 than in 2017 (2013, 71.6%). Of the 2232 neurosurgeons with scores in both years, 1347 (60.4%) improved their score. Reporting through an alternative payment model (odds ratio [OR]: 32.3, 95% CI: 16.0-65.4; P < .001) and any practice size larger than 10 (ORs ranging from 2.37 to 10.2, all P < .001) were associated with receiving bonus payments. Increasing years in practice (OR: 0.99; 95% CI: 0.982-0.998, P = .011) and having 25% to 49% (OR: 0.72; 95% CI: 0.53-0.97; P = .029) or ≥50% (OR: 0.48; 95% CI: 0.28-0.82; P = .007) of a physician's patients eligible for Medicaid were associated with lower rates of bonus payments. CONCLUSION: Neurosurgeons performed well in MIPS in 2017 and 2018, although the program may be biased against surgeons who practice in small groups or take care of socially disadvantaged patients.

Endovascular Intervention for May-Thurner Syndrome in a Pregnant Patient with a Patent Foramen Ovale and Paradoxical Embolism.

May-Thurner syndrome (MTS) is a known structural risk factor for deep vein thrombosis (DVT) and embolism. In patients with a patent foramen ovale (PFO), emboli originating from the deep veins are able to paradoxically reach the systemic circulation via the PFO, consequently resulting in transient ischemic attacks (TIA) or stroke.We report the case of a 31-year-old pregnant woman, with a recent history of TIA, who presented with chronic bilateral numbness, pain, and swelling in the lower extremities. On imaging, she was found to have a PFO and MTS. Her pregnancy was subsequently terminated. This decision was made independently by the patient. Her care team did not advise her to terminate her pregnancy as there was no specific medical reason to do so. However, the patient was in significant physical pain and distress and ultimately was not comfortable continuing with the pregnancy. This highlights the complex, multifactorial decision-making process that pregnant patients with comorbid health conditions undertake. The patient then underwent transcatheter PFO closure and stents were placed bilaterally in the left and right common iliac veins. Following the stent procedure, lower extremity symptoms swiftly resolved, allowing the patient to significantly improve her ability to ambulate. There have been no signs of TIA since her procedures, and her venous symptoms have been stable.In patients with TIA or stroke from a paradoxical embolism, MTS should be considered as a potential etiology. Endovascular intervention to treat the underlying MTS should also be considered to decrease the risk of recurrent DVT and embolism.

Prognostic Factors for Stage 3 Acute Kidney Injury in Isolated Serious Traumatic Brain Injury.

BACKGROUND: Stage 3 acute kidney injury (AKI) has been observed to develop after serious traumatic brain injury (TBI) and is associated with worse outcomes, though its incidence is not consistently established. This study aims to report the incidence of stage 3 AKI in serious isolated TBI in a large, national trauma database and explore associated predictive factors. METHODS: This was a retrospective cohort study using 2015-2018 data from the American College of Surgeons Trauma Quality Improvement Program, a national database of trauma patients. Adult trauma patients admitted to the hospital with isolated serious TBI were included. Variables relating to demographics, comorbidities, vitals, hospital presentation, and course of stay were assessed. Imputed multivariable logistic regression assessed factors predictive of stage 3 AKI development. RESULTS: A total of 342,675 patients with isolated serious TBI were included, 1585 (0.5%) of whom developed stage 3 AKI. Variables associated with stage 3 AKI in multivariable analysis were older age, male sex, Black race, higher body mass index, history of hypertension, diabetes, peripheral artery disease, chronic kidney disease, higher injury severity score, higher heart rate on arrival, lower oxygen saturation and motor Glasgow Coma Scale, admission to the intensive care unit or operating room, development of catheter-associated urinary tract infections or acute respiratory distress syndrome, longer intensive care unit stay, and ventilation duration. CONCLUSIONS: Stage 3 AKI occurred in 0.5% of serious TBI cases. Complications of acute respiratory distress syndrome and catheter-associated urinary tract infections are more likely to co-occur with stage 3 AKI in patients with serious TBI.

Compression Stocking Compliance Does Not Impact Reintervention or Symptom Change after Iliac Vein Stenting in Patients with Moderate to Severe Lower Extremity Edema.

BACKGROUND: Medical compression stocking (MCS) therapy remains a core treatment for chronic venous disease, particularly in patients with lower extremity edema. This study investigated the impact of postoperative MCS adherence on patients with moderate to severe edema who underwent iliac vein stenting (IVS). METHODS: Patients at a large tertiary care center who underwent IVS from August 2011 to June 2021 were analyzed. Symptoms were quantified using the venous clinical severity score (VCSS) and clinical assessment score (CAS). The criterion for inclusion was moderate or severe lower extremity edema at the time of IVS. Patients were stratified into two cohorts: complete postoperative compression therapy compliance (MCS+) and no postoperative compression therapy use (MCS-). RESULTS: Among 376 patients fitting our study criteria, we identified 168 MCS+ and 208 MCS- patients. The VCSS edema score did not significantly differ between groups (P = 0.179). Postoperatively, the mean changes in VCSS edema at the first postoperative visit, the one-year follow-up, and the two-year follow-up were not significantly different between the MCS+ and MCS- cohorts (P = 0.123, 0.296, and 0.534, respectively). An analysis of CAS for edema revealed that the MCS+ cohort had a modestly better improvement in edema at the 90-day follow-up visit versus the MCS- cohort (P = 0.018), but this difference was not observed in the 30-day (P = 0.834) or six-month follow-up visit (P = 0.755). A multivariate analysis revealed no difference in the need for major intervention (OR 0.93, 95% CI 0.44 to 1.50, P = 0.504). A Kaplan-Meier analysis via log-rank test revealed no difference in reintervention-free survival between groups (P = 0.77). CONCLUSIONS: Many patients with moderate to severe lower extremity edema experience a reduction in their edema after IVS. In our study, compression stocking compliance after surgery had a little impact on edema relief in this population.

Neurosurgical resection for locally recurrent brain metastasis.

BACKGROUND: In patients with locally recurrent brain metastases (LRBMs), the role of (repeat) craniotomy is controversial. This study aimed to analyze long-term oncological outcomes in this heterogeneous population. METHODS: Craniotomies for LRBM were identified from a tertiary neuro-oncological institution. First, we assessed overall survival (OS) and intracranial control (ICC) stratified by molecular profile, prognostic indices, and multimodality treatment. Second, we compared LRBMs to propensity score-matched patients who underwent craniotomy for newly diagnosed brain metastases (NDBM). RESULTS: Across 180 patients, median survival after LRBM resection was 13.8 months and varied by molecular profile, with >24 months survival in ALK/EGFR+ lung adenocarcinoma and HER2+ breast cancer. Furthermore, 102 patients (56.7%) experienced intracranial recurrence; median time to recurrence was 5.6 months. Compared to NDBMs (n = 898), LRBM patients were younger, more likely to harbor a targetable mutation and less likely to receive adjuvant radiation (P < 0.05). After 1:3 propensity matching stratified by molecular profile, LRBM patients generally experienced shorter OS (hazard ratio 1.67 and 1.36 for patients with or without a mutation, P < 0.05) but similar ICC (hazard ratio 1.11 in both groups, P > 0.20) compared to NDBM patients with similar baseline. Results across specific molecular subgroups suggested comparable effect directions of varying sizes. CONCLUSIONS: In our data, patients with LRBMs undergoing craniotomy comprised a subgroup of brain metastasis patients with relatively favorable clinical characteristics and good survival outcomes. Recurrent status predicted shorter OS but did not impact ICC. Craniotomy could be considered in selected, prognostically favorable patients.