A Pilot Study of the Serious Illness Conversation Guide in a Dialysis Clinic.

Clinician-led conversations about future care priorities occur infrequently with end-stage renal disease (ESRD) patients on dialysis. This was a pilot study of structured serious illness conversations using the Serious Illness Conversation Guide (SICG) in a single dialysis clinic to assess acceptability of the approach and explore conversation themes and potential outcomes among patients with ESRD. Twelve individuals with ESRD on dialysis from a single outpatient dialysis clinic participated in this study. Participants completed a baseline demographics survey, engaged in a clinician-led structured serious illness conversation, and completed an acceptability questionnaire. Conversations were recorded, transcribed and thematically analyzed. The average age of participants was 68.8 years. The conversations averaged 20:53 in length. Ten participants (83%) felt that the conversation was held at the right time in their clinical course and eleven participants (91%) felt that it was worthwhile. Most participants (73%) reported neutral feelings about clinician use of a printed guide. Eleven participants (91%) reported no change in anxiety about their illness following the conversation, and five participants (42%) reported that the conversation increased their hopefulness about future quality of life. Thematic analysis revealed common perspectives on dialysis including that participants view in-center hemodialysis as temporary, compartmentalize their kidney disease, perceive narrowed life experiences and opportunities, and believe dialysis is their only option. This pilot study suggests that clinician-led structured serious illness conversations may be acceptable to patients with ESRD on dialysis. The themes identified can inform future serious illness conversations with dialysis patients.

Influence of socioeconomic factors on discharge disposition following traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States.

Background: Discharge to acute rehabilitation is strongly correlated with functional recovery after traumatic injury, including spinal cord injury (SCI). However, services such as acute care rehabilitation and Skilled Nursing Facilities (SNF) are expensive. Our objective was to understand if high-cost, resource-intensive post-discharge rehabilitation or alternative care facilities are utilized at disparate rates across socioeconomic groups after SCI. Methods: We performed a cohort analysis using the National Trauma Data Bank® tabulated from 2012-2016. Eligible patients had a diagnosis of cervical or thoracic spine fracture with spinal cord injury (SCI) and were treated surgically. We evaluated associations of sociodemographic and psychosocial variables with non-home discharge (e.g., discharge to SNF, other healthcare facility, or intermediate care facility) via multivariable logistic regression while correcting for injury severity and hospital characteristics. Results: We identified 3933 eligible patients. Patients who were older, male (OR=1.29 95% Confidence Interval [1.07-1.56], p=.007), insured by Medicare (OR=1.45 [1.08-1.96], p=.015), diagnosed with a major psychiatric disorder (OR=1.40 [1.03-1.90], p=.034), had a higher Injury Severity Score (OR=5.21 [2.96-9.18], p<.001) or a lower Glasgow Coma Score (3-8 points, OR=2.78 [1.81-4.27], p<.001) had a higher chance of a non-home discharge. The only sociodemographic variable associated with lower likelihood of utilizing additional healthcare facilities following discharge was uninsured status (OR=0.47 [0.37-0.60], p<.001). Conclusions: Uninsured patients are less likely to be discharged to acute rehabilitation or alternative healthcare facilities following surgical management of SCI. High out-of-pocket costs for uninsured patients in the United States may deter utilization of these services.

Influence of Sociodemographic and Psychosocial Factors on Length of Stay After Surgical Management of Traumatic Spine Fracture with Spinal Cord Injury.

OBJECTIVE: Identifying patients at risk of increased health care resource utilization is a valuable opportunity to develop targeted preoperative and perioperative interventions. In the present investigation, we sought to examine patient sociodemographic factors that predict prolonged length of stay (LOS) after traumatic spine fracture. METHODS: We performed a cohort analysis using the National Trauma Data Bank tabulated during 2012-2016. Eligible patients were those who were diagnosed with cervical or thoracic spine fracture with spinal cord injury and who were treated surgically. We evaluated the effects of sociodemographic as well as psychosocial variables on LOS by negative binomial regression and adjusted for injury severity, injury mechanism, and hospital characteristics. RESULTS: We identified 3856 eligible patients with a median LOS of 9 days (interquartile range, 6-15 days). Patients in older age categories, who were male (incidence rate ratio (IRR), 1.05; 95% confidence interval [CI], 1.01-1.09), black (IRR, 1.12; CI, 1.05-1.19) or Hispanic (IRR, 1.09; CI, 1.03-1.16), insured by Medicaid (IRR, 1.24; CI, 1.17-1.31), or had a diagnosis of alcohol use disorder (IRR, 1.12; CI, 1.06-1.18) were significantly more likely to have a longer LOS. In addition, patients with severe injury on Injury Severity Score (IRR, 1.32; CI, 1.14-1.53) and lower Glasgow Coma Scale (GCS) scores (GCS score 3-8, IRR, 1.44; CI, 1.35-1.55; GCS score 9-11, IRR, 1.40; CI, 1.25-1.58) on admission had a significantly lengthier LOS. Patients admitted to a hospital in the Southern United States (IRR, 1.09; CI, 1.05-1.14) had longer LOS. CONCLUSIONS: Socioeconomic factors such as race, insurance status, and alcohol use disorder were associated with a prolonged LOS after surgical management of traumatic spine fracture with spinal cord injury.

Outcomes for Adults with Metabolic Syndrome Undergoing Elective Carotid Endarterectomy.

BACKGROUND: Metabolic syndrome (MetS) is a disorder characterized by a constellation of cardiometabolic risk factors including abdominal obesity, dyslipidemia, hypertension, and glucose intolerance that has been associated with adverse perioperative outcomes. We evaluated outcomes for patients with MetS after carotid endarterectomy (CEA) in the largest population to date. METHODS: We performed a matched cohort analysis using clinical data from 2012 to 2018 in the American College of Surgeons National Surgical Quality Improvement Program. We used propensity scores to match patients to attain covariate balance and used logistic regression to assess odds of unfavorable outcomes, including a predefined primary outcome of composite cardiovascular incident. RESULTS: We identified 50,423 eligible adult patients, of whom 14.2% qualified for MetS (n = 7156). Patients with MetS tended to have CEA at an earlier age, more functional dependence, and longer operative durations. After matching, MetS remained associated with the primary outcome of combined cardiovascular incident (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.18-1.72; P < 0.001), stroke (OR, 1.44; 95% CI, 1.12-1.85; P = 0.004), prolonged length of stay (OR, 1.31; 95% CI, 1.18-1.44; P < 0.001), and discharge to facility (OR, 1.32; 95% CI, 1.08-1.61; P = 0.007). We also found that obesity alone is protective against combined cardiovascular incident, whereas hypertension with diabetes and MetS increase odds of a cardiovascular complication. CONCLUSIONS: Metabolic syndrome is associated with adverse outcomes for adult patients undergoing elective CEA.

Socioeconomic and Psychosocial Predictors of Magnetic Resonance Imaging After Cervical and Thoracic Spine Trauma in the United States.

OBJECTIVE: Socioeconomic factors are known to influence outcomes after spinal trauma, but it is unclear how these factors affect health care utilization in acute care settings. We aimed to elucidate if sociodemographic and psychosocial factors are associated with obtaining magnetic resonance imaging (MRI), a costly imaging modality, after cervical or thoracic spine fracture. METHODS: Data from the 2012-2016 American College of Surgeons National Trauma Data Bank were used. We assessed the relationship between receipt of MRI and patient-level sociodemographic and psychosocial factors as well as hospital characteristics while correcting for injury-specific characteristics. Multiple logistic regression was performed to assess for associations between these variables and MRI after spine trauma. RESULTS: A total of 213,071 patients met the inclusion criteria, of whom 13.0% had an MRI (n = 27,757). After adjusting for confounders in multivariate regression, patients had increased odds of MRI if they were Hispanic (odds ratio [OR], 1.09; P = 0.001) or black (OR, 1.14; P < 0.001) or were diagnosed with major psychiatric disorder (OR, 1.06; P = 0.009), alcohol use disorder (OR, 1.05; P < 0.001), or substance use disorder (OR, 1.10; P < 0.001). Patients with Medicare (OR, 0.88; P < 0.001) or Medicaid (OR, 0.94; P < 0.011) were less likely to have an MRI than were those with private insurance, whereas patients treated in the Northeast (OR, 1.48; P < 0.001) or at for-profit hospitals (OR, 1.12; P < 0.001) were more likely. CONCLUSIONS: After adjusting for injury severity and spinal cord injury diagnosis, psychosocial comorbidities and for-profit hospital status were associated with higher odds of MRI, whereas public insurance was associated with lower odds. Results highlight potential biases in the provision of MRI as a costly imaging modality.

Influence of psychosocial and sociodemographic factors in the surgical management of traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States.

BACKGROUND: Socioeconomic factors can bias clinician decision-making in many areas of medicine. Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, and major psychiatric disorder are emerging as potential sources of conscious and unconscious bias. We hypothesized that these psychosocial factors, in addition to socioeconomic factors, may impact the decision to operate on patients with a traumatic cervicothoracic fracture and associated spinal cord injury (SCI). METHODS: We performed a cohort analysis using clinical data from 2012-2016 in the American College of Surgeons (ACS) National Trauma Data Bank at academic level I and II trauma centers. Patients were eligible if they had a diagnosis of cervicothoracic fracture with SCI. Using ICD codes, we evaluated baseline characteristics including race; insurance status; diagnosis of alcoholism, substance abuse, or major psychiatric disorder; admission drug screen and blood alcohol level; injury characteristics and severity; and hospital characteristics including geographic region, non-profit status, university affiliation, and trauma level. Factors significantly associated with surgical intervention in univariate analysis were eligible for inclusion in multivariate logistic regression. RESULTS: We identified 6,655 eligible patients, of whom 62% underwent surgical treatment (n=4,137). Patients treated non-operatively were more likely to be older; be female; be Black or Hispanic; have Medicare, Medicaid, or no insurance; have been assaulted; have been injured by a firearm; have thoracic fracture; have less severe injuries; have severe TBI; be treated at non-profit hospitals; and be in the Northeast or Western U.S. (all P<0.01). After adjusting for confounders in multivariate analysis, only insurance status remained associated with operative treatment. Medicaid patients (OR=0.81; P=0.021) and uninsured patients (OR=0.63; P<0.001) had lower odds of surgery relative to patients with private insurance. Injury severity and facility characteristics also remained significantly associated with surgical management following multivariate regression. CONCLUSIONS: Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, or psychiatric illness do not appear to bias the decision to operate after traumatic cervicothoracic fracture with SCI. Baseline sociodemographic imbalances were explained largely by insurance status, injury, and facility characteristics in multivariate analysis.

Operative duration and early outcomes in patients having a supratentorial craniotomy for brain tumor: A propensity matched analysis.

It is unclear how variations in operative duration affect outcomes after craniotomy for supratentorial brain tumor. We characterized three populations of patients with typical, shorter, and longer durations of craniotomy for supratentorial brain tumor using prospectively collected clinical data from 16,335 patients in the 2012-2018 ACS National Surgical Quality Improvement Program (NSQIP) database. We compared baseline characteristics including demographics, comorbidities, tumor type, and operative features. We used propensity score matching to attain covariate balance and logistic regression to assess odds of unfavorable outcomes. Patients with the shortest operation durations tended to be older, with fewer males, higher ASA class, more metastatic brain tumors, more medical comorbidities, and less use of intraoperative microscope or ultrasound. Patients with the longest operative durations tended to be younger, with more males, fewer non-white minorities, more obesity, lower ASA classes, more intrinsic brain tumors, fewer medical comorbidities, fewer emergency operations, and increased use of intraoperative microscope. For patients with the shortest operations, after matching, we observed significantly decreased odds of prolonged length-of-stay (LOS), major complication, any complication, reoperation, and discharge to a facility; however, there was a significantly increased risk of 30-day mortality. For patients with the longest operations, after matching, we observed significantly increased odds of prolonged LOS; minor, major, and any complication; discharge to facility; and 30-day reoperation. After matching to balance baseline characteristics, operative duration has implications for outcomes following craniotomy for supratentorial brain tumor.

Short term outcomes associated with patients requiring blood transfusion following elective laminectomy and fusion for lumbar stenosis: A propensity-matched analysis.

Perioperative blood transfusion has been associated with poor outcomes but the impacts of transfusion after fusion for lumbar stenosis have not been well-described. We assessed this effect in a large cohort of patients from 2012 to 2018 in the National Surgical Quality Improvement Program (NSQIP). We evaluated baseline characteristics including demographics, comorbidities, hematocrit, and operative characteristics. We generated propensity scores using baseline characteristics and patients were matched to approximate randomization. We assessed odds of 30-day outcomes including prolonged length-of-stay (LOS), complications, discharge to facility, readmission, reoperation, and death using logistic regression. We identified 16,329 eligible patients who underwent lumbar fusion for stenosis; 1,926 (11.8%) received a transfusion. Before matching, there were multiple differences in baseline covariates including age, gender, BMI, ASA class, medical comorbidities, hematocrit, coagulation indices, platelets, operative time, fusion technique, number of levels fused, and osteotomy. However, after matching, no significant differences remained. In the matched cohorts, transfusion was associated with increased prolonged LOS (OR 1.66, 95% CI 1.45-1.91, p < 0.001), minor complication (OR 1.60, 95% CI 1.20-2.12, p = 0.001), major complication (OR 1.51, 95% CI 1.16-1.98, p = 0.003), any complication (OR 1.54, 95% CI 1.24-1.92, p < 0.001), discharge to facility (OR 1.70, 95% CI 1.48-1.95, p < 0.001), 30-day readmission (OR 1.56, 95% CI 1.23-1.99, p < 0.001), and 30-day reoperation (OR 1.85, 95% CI 1.35-2.53, p < 0.001). Although transfusion is performed based on perceived clinical need, this study contributes to growing evidence that it is important to balance the risks of perioperative blood transfusion with its benefits.

Early Outcomes After Carotid Endarterectomy and Carotid Artery Stenting: A Propensity-Matched Cohort Analysis.

BACKGROUND: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) represent options to treat many patients with carotid stenosis. Although randomized trial data are plentiful, estimated rates of morbidity and mortality for both CEA and CAS have varied substantially. OBJECTIVE: To evaluate rates of adverse outcomes after CAS and CEA in a large national database. METHODS: We analyzed 84 191 adult patients undergoing elective, nonemergent CAS (n = 81 361) or CEA (n = 2830), from 2011 to 2018, in the American College of Surgeons' National Surgical Quality Improvement Program database. Odds of adverse outcomes (30-d rates of stroke, myocardial infarction (MI), cardiac arrest, prolonged length of stay (LOS), readmission, reoperation, and mortality) were evaluated in propensity-matched (n = 2821) cohorts through logistic regression. RESULTS: In the propensity-matched cohorts, CAS had increased odds of periprocedural stroke (odds ratio [OR] 1.97, 95% CI 1.32-2.95) and decreased odds of cardiac arrest (OR 0.33, 95% CI 0.13-0.84) and 30-d reoperation (OR 0.59, 95% CI 0.44-0.80) compared to CEA. Relative odds of MI, prolonged LOS, discharge to destination other than home, 30-d readmission, or 30-d mortality were statistically similar. In the unmatched patient population, rates of adverse outcomes with CEA were constant over time; however, for CAS, rates of stroke increased over time. In both the matched and unmatched patient cohorts, patients 70 yr and older had lower rates of post-procedural stroke with CEA, but not with CAS, compared to younger patients. CONCLUSION: In a propensity-matched analysis of a large, prospectively collected, national, surgical database, CAS was associated with increased odds of periprocedural stroke, which increased over time. Rates of MI and death were not significantly different between the 2 procedures.

Outcomes of infratentorial cranial surgery for tumor resection in older patients: An analysis of the National Surgical Quality Improvement Program.

BACKGROUND: Poorer outcomes for infratentorial tumor resection have been reported. There is a lack of large multicenter analyses describing infratentorial surgery outcomes in older patients. We characterized outcomes in patients aged ≥65 years undergoing infratentorial cranial surgery. METHODS: The National Surgical Quality Improvement Project database was queried from 2012 to 2018 for patients ≥18 years undergoing elective infratentorial cranial surgery for tumor resection. Patients were grouped into 65-74 years, ≥75 years, and 18-64 years cohorts. Multivariable regressions compared outcome measures. RESULTS: Of 2212 patients, 28.3% were ≥65 years, of whom 24.8% were ≥75 years. Both older subpopulations had worse American Society of Anesthesiologists classification compared to controls (P < 0.01) and more comorbidities. Patients 65-74 and ≥75 years had higher rates of major complication (adjusted odds ratio [aOR] = 1.77, 95% CI = 1.13-2.79 and aOR = 3.44, 95% CI = 1.96-6.02, respectively), prolonged length of stay (LOS) (aOR = 1.89, 95% CI = 1.15-3.12 and aOR = 3.00, 95% CI = 1.65-5.44, respectively), and were more likely to be discharged to a location other than home (aOR = 2.43, 95% CI =1.73-3.4 and aOR = 3.41, 95% CI = 2.18-5.33, respectively) relative to controls. Patients ≥75 had higher rates of readmission (aOR = 1.86, 95% CI = 1.13-3.08) and mortality (aOR = 3.28, 95% CI = 1.21-8.89) at 30 days. CONCLUSION: Patients ≥65 years experienced more complications, prolonged LOS, and were less often discharged home than adults <65 years. Patients ≥75 years had higher rates of 30-day readmission and mortality. There is a need for careful preoperative optimization in older patients undergoing infratentorial tumor cranial surgery.

Urinary Tract Infection after Elective Spine Surgery: Timing, Predictive Factors, and Outcomes.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: The aim of this study was to investigate risk factors associated with the timing of urinary tract infection (UTI) after elective spine surgery, and to determine whether postoperative UTI timing affects short-term outcomes. SUMMARY OF BACKGROUND DATA: Urinary tract infection (UTI) is a common post-surgical complication; however, the predominant timing, location, and potential differential effects have not been carefully studied. METHODS: We analyzed elective spine surgery patients from 2012 to 2018 in the ACS National Surgical Quality Improvement Program (NSQIP). We grouped patients with postoperative UTI by day of onset relative to discharge, to create cohorts of patients who developed inpatient UTI and post-discharge UTI. We compared both UTI cohorts with a control (no UTI) population and with each other to identify differences in baseline characteristics including demographic, comorbidity and operative factors. We performed multivariate logistic regression to identify predictors of UTI in each cohort and to assess adjusted risks of poor outcomes associated with UTI timing. RESULTS: A total of 289,121 patients met inclusion criteria and 0.88% developed UTI (n = 2553). Only 31.6% of UTIs occurred before discharge (n = 806), with 68.4% occurring after discharge (n = 1747). The inpatient UTI cohort had significantly longer operative time, more fusion procedures, more posterior procedures, and more procedures involving the lumbar levels than the post-discharge cohort. Predictors of inpatient UTI included procedure type, spine region, and approach. Predictors of post-discharge UTI included length-of-stay and discharge destination. Both UTI cohorts were significantly associated with sepsis; however, post-discharge UTI carried a higher odds (adjusted odds ratio [aOR] = 24.90, 95% confidence interval [CI] = 21.05-29.45, P < 0.001 vs. aOR = 14.31, 95% CI = 11.09-18.45, P < 0.001). Inpatient UTI was not associated with 30-day readmission, although post-discharge UTI was (aOR = 8.23, 95% CI = 7.36-9.20, P < 0.001). Conversely, inpatient UTI was associated with increased odds of 30-day mortality (aOR = 3.23, 95% CI = 1.62-6.41, P = 0.001), but post-discharge UTI was not. CONCLUSION: Predictive factors and outcomes differ based on timing of UTI after elective spine surgery. Before discharge, procedure -specific details predict UTI, but after discharge they do not. These findings suggest that traditional thinking about UTI prevention may need modification.Level of Evidence: 3.

A modern multidisciplinary approach to a large cervicothoracic chordoma using staged en bloc resection with intraoperative image-guided navigation and 3D-printed modeling: illustrative case.

BACKGROUND: Cervicothoracic junction chordomas are uncommon primary spinal tumors optimally treated with en bloc resection. Although en bloc resection is the gold standard for treatment of mobile spinal chordoma, tumor location, size, and extent of involvement frequently complicate the achievement of negative margins. In particular, chordoma involving the thoracic region can require a challenging anterior access, and en bloc resection can lead to a highly destabilized spine. OBSERVATIONS: Modern technological advances make en bloc resection more technically feasible than ever before. In this case, the successful en bloc resection of a particularly complex cervicothoracic junction chordoma was facilitated by a multidisciplinary surgical approach that maximized the use of intraoperative computed tomography-guided spinal navigation and patient-specific three-dimensional-printed modeling. LESSONS: The authors review the surgical planning and specific techniques that facilitated the successful en bloc resection of this right-sided chordoma via image-guided parasagittal osteotomy across 2 stages. The integration of emerging visualization technologies into complex spinal column tumor management may help to provide optimal oncological care for patients with challenging primary tumors of the mobile spine.

Three-Dimensional Printed Anatomic Modeling for Surgical Planning and Real-Time Operative Guidance in Complex Primary Spinal Column Tumors: Single-Center Experience and Case Series.

OBJECTIVE: Three-dimensional (3D) printing has emerged as a visualization tool for clinicians and patients. We sought to use patient-specific 3D-printed anatomic modeling for preoperative planning and live intraoperative guidance in a series of complex primary spine tumors. METHODS: Over 9 months, patients referred to a single neurosurgical provider for complex primary spinal column tumors were included. Most recent spinal magnetic resonance and computed tomography (CT) imaging were semiautomatically segmented for relevant anatomy and models were printed using polyjet multicolor printing technology. Models were available to surgical teams before and during the operative procedure. Patients also viewed the models preoperatively during surgeon explanation of disease and surgical plan to aid in their understanding. RESULTS: Tumor models were prepared for 9 patients, including 4 with chordomas, 2 with schwannomas, 1 with osteosarcoma, 1 with chondrosarcoma, and 1 with Ewing-like sarcoma. Mean age was 50.7 years (range, 15-82 years), including 6 males and 3 females. Mean tumor volume was 129.6 cm3 (range, 3.3-250.0 cm3). Lesions were located at cervical, thoracic, and sacral levels and were treated by various surgical approaches. Models were intraoperatively used as patient-specific anatomic references throughout 7 cases and were found to be technically useful by the surgical teams. CONCLUSIONS: We present the largest case series of 3D-printed spine tumor models reported to date. 3D-printed models are broadly useful for operative planning and intraoperative guidance in spinal oncology surgery.

Supplementation of Screw-Rod C1-C2 Fixation With Posterior Arch Femoral Head Allograft Strut.

BACKGROUND: Numerous C1-C2 fixation techniques exist for the treatment of atlantoaxial instability. Limitations of screw-rod and sublaminar wiring techniques include C2 nerve root sacrifice and dural injury, respectively. We present a novel technique that utilizes a femoral head allograft cut with a keyhole that rests posteriorly on the arches of C1 and C2 and straddles the C2 spinous process, secured by sutures. OBJECTIVE: To offer increased fusion across C1-C2 without the passage of sublaminar wiring or interarticular arthrodesis. METHODS: A total of 6 patients with atlantoaxial instability underwent C1-C2 fixation using our method from 2015 to 2016. After placement of a C1-C2 screw/rod construct, a cadaveric frozen femoral head allograft was cut into a half-dome with a keyhole and placed over the already decorticated dorsal C1 arch and C2 spinous process. Notches were created in the graft and sutures were placed in the notches and around the rods to secure it firmly in place. RESULTS: The femoral head's shape allowed for creation of a graft that provides excellent surface area for fusion across C1-C2. There were no intraoperative complications, including dural tears. Postoperatively, no patients had sensorimotor deficits, pain, or occipital neuralgia. 5 patients demonstrated clinical resolution of symptoms by 3 mo and radiographic (computed tomography) evidence of fusion at 1 yr. One patient had good follow-up at 1 mo but died due to complications of Alzheimer disease. CONCLUSION: The posterior arch femoral head allograft strut technique with securing sutures is a viable option for supplementing screw-rod fixation in the treatment of complex atlantoaxial instability.

Early outcomes of supratentorial cranial surgery for tumor resection in older patients.

With longevity increasing in the United States, more older individuals are presenting with supratentorial brain tumors. Despite improved perioperative management, there is persistent disparity in surgical resection rates among patients aged 65 years or older. We aim to assess the effects of advanced age (≥65 years) on 30-day outcomes in patients with supratentorial tumors who underwent craniotomy for supratentorial tumor resection. Data obtained in adults who underwent supratentorial tumor resections was extracted from the prospectively-collected American College of Surgeons: National Surgical Quality Improvement Program (NSQIP; 2012-2018) database. Using multivariate regression, we compared odds of major and minor complications; prolonged length-of-stay (LOS); discharge anywhere other than home; and 30-day readmission, reoperation, and mortality rates between patients aged 18-64 years (the control cohort) and those 65-74 years or ≥75 years of age. Of the 14,234 patients who underwent craniotomy for supratentorial tumors and met inclusion criteria, 30.7% were ≥65 years of age; 71.4% of these were 65-74 years and 28.6% were ≥75 years old. Compared to the control group, both older subpopulations had more medical comorbidities. Both older subgroups had increased odds of major complications and prolonged LOS relative to the control group. Older patients had greater odds of mortality at 30 days. Advanced age, defined as ≥65 years, was significantly associated with higher odds of complications, prolonged LOS, and mortality within the 30-day post- operative period after adjusting for potential confounders. Age is one important consideration when prospectively risk-stratifying patients to minimize and mitigate suboptimal perioperative outcomes.

Frailty and outcomes after craniotomy for brain tumor.

Frailty has been associated with increased morbidity and mortality in a variety of surgical disciplines. Few data exist regarding the relationship of frailty with adverse outcomes in craniotomy for brain tumor resection. We assessed the relationship between frailty and the incidence of major post-operative complication, discharge destination other than home, 30-day readmission, and 30-day mortality after elective craniotomy for brain tumor resection. A retrospective cohort study was conducted on 20,333 adult patients undergoing elective craniotomy for tumor resection in the 2012-2018 ACS-NSQIP Participant Use File. Multivariate logistic regression was performed using all covariates deemed eligible through clinical and statistical significance. 6,249 patients (30.7%) were low-frailty and 2,148 patients (10.6%) were medium-to-high frailty. In multivariate logistic regression adjusting for age, gender, BMI, ASA classification, smoking status, dyspnea, significant pre-operative weight loss, chronic steroid use, bleeding disorder, tumor type, and operative time, low frailty was associated with increased adjusted odds ratio of major complication (1.41, 95% CI: 1.23-1.60, p < 0.001), discharge destination other than home (1.32, 95% CI: 1.20-1.46, p < 0.001), 30-day readmission (1.29, 95% CI: 1.15-1.44, p < 0.001), and 30-day mortality (1.87, 95% CI: 1.41-2.47, p < 0.001). Moderate-to-high frailty was also associated with increased adjusted odds of major complication (1.61, 95% CI: 1.35-1.92, p < 0.001), discharge destination other than home (1.80, 95% CI: 1.58-2.05), 30-day readmission (1.39, 95% CI: 1.19-1.62, p < 0.001), and 30-day mortality (2.42, 95% CI: 1.74-3.38, p < 0.001). CONCLUSIONS: Frailty is associated with increased odds of major post-operative complication, discharge to destination other than home, 30-day readmission, and 30-day mortality.

Sepsis after elective neurosurgery: Incidence, outcomes, and predictive factors.

Sepsis is a life-threatening condition resulting from systemic infection, with mortality rates approaching 30%. Most neurological surgeries are now performed electively, which permits medical optimization preoperatively. We performed a retrospective cohort analysis of 122,466 adult elective neurosurgical patients from 2012 to 2018 in the National Surgical Quality Improvement Program database. To select for a medically optimized population, patients were included if they arrived from home on the day of surgery, were not pregnant or puerperium, and had no documented evidence of preexisting infection. We analyzed demographic, comorbidity, and operative information; performed multivariate logistic regression to explore factors predictive of postoperative sepsis; and evaluated outcomes for patients who developed sepsis. Overall, 0.87% of patients developed postoperative sepsis (n = 1,067). The rate of sepsis was higher in the cranial subpopulation (1.21%; n = 330) and lower in the spinal subpopulation (0.77%; n = 733). The overall sepsis cohort was older, had more males, was more functionally dependent, had longer operation durations, and had higher rates of medical comorbidities. Minority race and smoking were not associated with sepsis. The sepsis cohort fared worse than the control cohort across all outcome measures, including prolonged length-of-stay (≥90th percentile), discharge anywhere but home, 30-day readmission, 30-day reoperation, and 30-day mortality. Results for the cranial and spine subpopulations follow similar trends. In summary, sepsis in the elective neurosurgical population is an uncommon but devastating cause of excess morbidity and mortality.

Conversations About Goals and Values Are Feasible and Acceptable in Long-Term Acute Care Hospitals: A Pilot Study.

RATIONALE: The chronically critically ill have survived acute critical illness but require prolonged mechanical ventilation. These patients are frequently transferred from acute care to long-term acute care hospitals (LTACHs) for prolonged recovery, yet many suffer setbacks requiring readmission to acute care. The patient's relatively improved condition while at the LTACH might be an opportunity for communication regarding care goals; however, there have been no prior studies of the feasibility of such conversations in the LTACH. OBJECTIVES: To determine the feasibility, acceptability, and potential usefulness of conversations about serious illness with chronic critical illness patients or their surrogate decision makers after LTACH admission. METHODS: We adapted an existing conversation guide for use in chronically critically ill (defined by tracheotomy for prolonged ventilation) LTACH patients or their surrogates to explore views about quality of life, understanding of medical conditions, expectations, and planning for setbacks. These conversations were conducted by one interviewer and summarized for the patients' clinicians. We surveyed patients, surrogates, and clinicians to assess acceptability. MEASUREMENT AND MAIN RESULTS: A total of 70 subjects were approached and 50 (71%) were enrolled, including 30 patients and 20 surrogates. The median duration of the conversation was 14 minutes 45 seconds [IQR 12:46, 19]. The presence of ongoing mechanical ventilation did not lead to longer conversations; in fact, conversations with patients were shorter than those with surrogates. The majority of subjects (81%) described the conversation as worthwhile. The majority of clinicians (73%) reported that the conversation offered a new and significant understanding of the patient's preferences if a setback were to occur. CONCLUSIONS: Conversations about serious illness care goals can be accomplished in a relatively short period of time, are acceptable to chronically critically ill patients and their surrogate decision makers in the LTACH, and are perceived as worthwhile by patients, surrogates, and clinicians.

Opening the Door: The Experience of Chronic Critical Illness in a Long-Term Acute Care Hospital.

OBJECTIVE: Chronically critically ill patients have recurrent infections, organ dysfunction, and at least half die within 1 year. They are frequently cared for in long-term acute care hospitals, yet little is known about their experience in this setting. Our objective was to explore the understanding and expectations and goals of these patients and surrogates. DESIGN: We conducted semi-structured interviews with chronically critically ill long-term acute care hospital patients or surrogates. Conversations were recorded, transcribed, and analyzed. SETTING: One long-term acute care hospital. SUBJECTS: Chronically critically ill patients, defined by tracheotomy for prolonged mechanical ventilation, or surrogates. INTERVENTION: Semi-structured conversation about quality of life, expectations, and planning for setbacks. MEASUREMENTS AND MAIN RESULTS: A total of 50 subjects (30 patients and 20 surrogates) were enrolled. Thematic analyses demonstrated: 1) poor quality of life for patients; 2) surrogate stress and anxiety; 3) optimistic health expectations; 4) poor planning for medical setbacks; and 5) disruptive care transitions. Nearly 80% of patient and their surrogate decision makers identified going home as a goal; 38% were at home at 1 year. CONCLUSIONS: Our study describes the experience of chronically critically ill patients and surrogates in an long-term acute care hospital and the feasibility of patient-focused research in this setting. Our findings indicate overly optimistic expectations about return home and unmet palliative care needs, suggesting the need for integration of palliative care within the long-term acute care hospital. Further research is also needed to more fully understand the challenges of this growing population of ICU survivors.