Examining barriers to care: a retrospective cohort analysis investigating the relationship between hospital volume and outcomes in pediatric patients with cerebral arteriovenous malformations.

OBJECTIVE: Comprehensive data on treatment patterns of pediatric cerebral arteriovenous malformations (AVMs) are lacking. The authors' aim was to examine national trends, assess the effect of hospital volume on outcomes, and identify variables associated with treatment at high-volume centers. METHODS: Pediatric AVM admissions (for ruptured and unruptured lesions) occurring in the US in 2016 and 2019 were identified using the Kids' Inpatient Database. Demographics, treatment methods, costs, and outcomes were recorded. The effect of hospital AVM volume on outcomes and factors associated with treatment at higher-volume hospitals were analyzed. RESULTS: Among 2752 AVM admissions identified, 730 (26.5%) patients underwent craniotomy, endovascular treatment, or a combination. High-volume (vs low-volume) centers saw lower proportions of Black (8.7% vs 12.9%, p < 0.001) and lowest-income quartile (20.7% vs 27.9%, p < 0.001) patients, but were more likely to provide endovascular intervention (19.5%) than low-volume institutions (13.7%) (p = 0.001). Patients treated at high-volume hospitals had insignificantly lower numbers of complications (mean 2.66 vs 4.17, p = 0.105) but significantly lower odds of nonroutine discharge (OR 0.18 [95% CI 0.06-0.53], p = 0.009) and death (OR 0.13 [95% CI 0.02-0.75], p = 0.023). Admissions at high-volume hospitals cost more than at low-volume hospitals, regardless of whether intervention was performed ($64,811 vs $48,677, p = 0.001) or not ($64,137 vs $33,779, p < 0.001). Multivariable analysis demonstrated that Hispanic children, patients who received AVM treatment, and those in higher-income quartiles had higher odds of treatment at high-volume hospitals. CONCLUSIONS: In this largest study of US pediatric cerebral AVM admissions to date, higher hospital volume correlated with several better outcomes, particularly when patients underwent intervention. Multivariable analysis demonstrated that higher income and Hispanic race were associated with treatment at high-volume centers, where endovascular care is more common. The findings highlight the fact that ensuring access to appropriate treatment of patients of all races and socioeconomic classes must be a focus.

Efecto de la edad en el pronóstico de pacientes con traumatismo craneoencefálico sometidos a craneotomía: análisis de una serie quirúrgica / The effect of age on the prognosis of patients with traumatic brain injury who undergo a craniotomy: analysis of a surgical series

Introducción. En nuestro entorno, el envejecimiento poblacional ha convertido el manejo del traumatismo craneoencefálico (TCE) en etapas avanzadas de la vida en un problema de frecuencia creciente.Objetivo. Valorar la asociación entre la edad y el pronóstico vital y funcional de pacientes intervenidos por TCE. Pacientes y métodos. Analizamos retrospectivamente una serie de 404 pacientes intervenidos en nuestro centro entre los años 2000 y 2015: 144 jóvenes (12-44 años), 77 adultos (45-64 años), 148 pacientes geriátricos (65-79 años) y 26 supergeriatricos (> 80 años). Revisamos las características demográficas y nosológicas de la población, y el pronóstico vital y funcional (escala pronostica de Glasgow, GOS) en el momento del alta y a los seis meses. Resultados. La edad presenta asociación lineal positiva tanto con la mortalidad intrahospitalaria como con la proporción de pacientes con pronóstico desfavorable (GOS 1-3) en el alta y a los seis meses (p < 0,001). Tomando como referencia la población de jóvenes, el riesgo relativo para pronostico desfavorable a los seis meses fue de 1,5 (IC 95%: 1,04-2,19) para los adultos, 2,37 (IC 95%: 1,77-3,17) para los geriátricos y 3,5 (IC 95%: 2,63-4,70) para los supergeriatricos. Estos últimos presentan una mortalidad durante el ingreso del 77,78% y un porcentaje de mal pronóstico funcional a los seis meses del 94,44%. Conclusión. El aumento de la edad es un factor determinante negativo mayor en el pronóstico de pacientes sometidos a craneotomía por TCE. Un conocimiento preciso de estos resultados y una adecuada discusión preoperatoria con la familia resultaran de gran ayuda en el proceso de toma de decisiones (AU)

Introduction. In our setting, the ageing of the population has led to management of traumatic brain injury (TBI) in the later stages of life becoming an increasingly frequent problem. Aim. To evaluate the association between age and the functional and survival prognosis of patients who have undergone surgery due to TBI. Patients and methods. We performed a retrospective analysis of a series of 404 patients submitted to surgery between the years 2000 and 2015: 144 youngsters (12-44 years), 77 adults (45-64 years), 148 geriatric patients (65-79 years) and 26 'super geriatric' patients (> 80 years). We reviewed the demographic and nosological characteristics of the population, the survival and functional prognosis (Glasgow Outcome Scale, GOS) on discharge and at six months. Results. Age presents a positive linear association with both intra-hospital mortality and the proportion of patients with an unfavourable prognosis (GOS 1-3) on hospital discharge and at six months (p < 0.001). Taking the population of youngsters as a reference, the relative risk for an unfavourable prognosis at six months was 1.5 (95% CI: 1.04-2.19) for adults; 2.37 (95% CI: 1.77-3.17) for the geriatric patients; and 3.5 (95% CI: 2.63-4.7) for the ‘super geriatric’ patients. These latter present a mortality rate while in hospital of 77.78% and a percentage of poor functional prognosis at six months of 94.44%. Conclusion. Increased age is a major negative determining factor in the prognosis of patients who undergo a craniotomy due to TBI. More precise knowledge of these outcomes and an adequate pre-operative discussion with the family will be an invaluable aid in the decision-making process (AU)

Factores asociados a infecciones nosocomiales en sitio quirúrgico para craneotomía / Factors associated with nosocomial surgical-site infections for craniotomy in Mexico City hospitals

Introducción: La infección nosocomial en sitio quirúrgico (INSQ) en craneotomía puede ocasionar la muerte o discapacidad que modifica la calidad de vida, por lo que se requiere encontrar factores que puedan ser utilizados para incluir en los índices de control. Por ello es necesario identificar factores asociados a esta infección y obtener el riesgo de infección atribuible y comparar su capacidad predictiva con el índice del NNISS (Sistema de Vigilancia Nacional de Infecciones Nosocomiales de Estados Unidos). Material y métodos: Se realizó un estudio de casos y controles durante dos años, en pacientes con craneotomía en hospitales del Instituto Mexicano del Seguro Social. Los pacientes cumplieron los criterios de los Centros de Control de Enfermedades de Atlanta para INSQ. Resultados: Se practicaron 737 craneotomías durante el estudio, 41 pacientes presentaron INSQ. Factores intrínsecos asociados: presencia de enfermedades crónicas (OR = 2.18) y craneotomía debida a causas no traumáticas (OR = 1.87); factores extrínsecos: turno vespertino (OR = 2.6) y la práctica de otra cirugía en el mismo sitio quirúrgico (OR = 5.2). Estos factores conformaron los índices de factores intrínsecos y extrínsecos. Con factores extrínseco se presentó 1.7 veces más riesgo en comparación con los factores intrínsecos, así como mayor área bajo la curva ROC (0.731). El riesgo con el índice NNISS con un factor fue de 1.5 y con dos a tres factores, de 4.7. Conclusiones: En esta población en estudio, los pacientes sometidos a una craneotomía tuvieron mayor asociación a INSQ con los factores extrínsecos.

BACKGROUND: Nosocomial surgical-site infection (NSSI) after craniotomy is responsible for an increase in deaths and/or disabilities that affect quality of life. It is necessary to identify factors to be included in an index for their control. The aim of this study was to a) identify intrinsic and extrinsic factors associated with NSSI after craniotomy and b) obtain the infection risk attributed to both intrinsic and extrinsic factors as well as to compare their predictive capability with the NNISS (National Nosocomial Infection Surveillance System) index. METHODS: A case-control study was conducted during a 2-year period in patients who underwent craniotomy in hospitals affiliated with the Instituto Mexicano del Seguro Social. Patients were selected according to the Centers for Disease Control and Prevention criteria for NSSI. RESULTS: During the study period 737 craniotomies were performed, 41 of which presented with NSSI. Intrinsic factors associated with NSSI were the presence of chronic diseases (OR = 2.18) and craniotomy due to nontraumatic causes (OR = 1.87), whereas extrinsic factors were procedures performed during the late shift (OR = 2.6) and another surgery at the same surgical site (OR = 5.2). These factors comprised the index with intrinsic and extrinsic factors. Extrinsic factors were 1.7 times higher than intrinsic factors, in addition to having a larger area under the ROC curve (0.731). The risk obtained with the NNISS index for patients who had one factor was 1.5, whereas that for patients who had two or three factors was 4.7. CONCLUSIONS: In the studied population, patients who underwent a craniotomy with extrinsic factors showed a higher association with NSSI.

Factores de riesgo asociados a las complicaciones del tratamiento quirúrgico de losquistes aracnoideos intracraneales en pacientes adultos. Análisis retrospectivo de una serie de casos / Risk factors associated with the complications of surgical treatment of intracranial arachnoid cysts in adult patients. Retrospective case series analysis

Introducción. Analizamos los resultados quirúrgicosen pacientes adultos operados de quiste aracnoideointracraneal, evaluando las diferentes técnicas quirúrgicasempleadas, la vida media de cada procedimientoy el índice de complicaciones postquirúrgicas. Este estudiodescribe los resultados de nuestra institución.Material y métodos. Incluimos a todos los pacientesoperados con diagnóstico de quiste aracnoideointracraneal desde enero de 2001 hasta diciembre del2006. Se evaluó la eficacia de cada técnica quirúrgicaempleada y la vida media de cada procedimiento, asícomo los eventos adversos asociados al tratamiento quirúrgico.Resultados. La distribución por género fue 15 hombresy 13 mujeres, con un promedio de edad de 34 añosy con un rango de 17 a 65 años al momento de la cirugía.El síntoma predominante fue la cefalea. La localizaciónde los QA fue: 24 supratentoriales y 4 infratentoriales.Se realizaron 48 cirugías; se presentaron complicacionespostquirúrgicas en 11 pacientes del grupo deestudio. La craneotomía fue el procedimiento con unavida más prolongada (1245 días). La vida media de lacraneotomía más fenestración fue significativamentemayor que el resto de los procedimientos (853 vs 193días con una P: 0.0333) y el quiste aracnoideo grado IIIde Galassi es un factor de riesgo para reoperación ennuestro grupo de estudio con una razón de momios de13.417.Conclusión. La fenestración por craneotomía fueen la experiencia de este hospital el procedimiento conmenores complicaciones y mayor tiempo de efectividad.Las complicaciones del tratamiento quirúrgico estánfuertemente relacionadas con la ubicación y el tamañodel quiste (AU)

Introduction. We analyzed the surgical results inpatients operated for an arachnoid cyst evaluating thedifferent surgical techniques employed, the average lifeof each procedure and the rate of postoperative complications.This study describes the results from ourinstitution.Material and methods. We included all patients operatedwith a diagnosis of intracranial arachnoid cystfrom January 2001 to December 2006. We evaluatedthe effectiveness of each surgical technique and theaverage life of each procedure, as well as adverse eventsassociated with surgical treatment.Results. The gender distribution was 15 men and 13women, with an average of 34 years and with a rangeof 17 to 65 years at time of surgery. The predominantsymptom was headache. The location of the arachnoidcyst was 24 supratentorial and 4 infratentorial. 48 surgerieswere performed. There were complications in 11patients in the study group; the craniotomy was the procedurewith a longer life (1245 days). The half-life of thecraniotomy more fenestration was significantly higherthan the rest of the procedures (853 vs. 193 days with aP: 0.0333) and the arachnoid cyst grade III of Galassi isa risk factor for reoperative in our study group with anodds ratio of 13,417.Conclusion. In our experience the fenestration bycraniotomy was the procedure with fewer complicationsand increased time of effectiveness. Treatmentcomplications are strongly related to cyst location andsize (AU)