A Novel Approach to Avoid Baclofen Withdrawal When Faced With Infected Baclofen Pumps.

BACKGROUND: Intrathecal (IT) Baclofen is beneficial for spasticity, but if pumps become infected necessitating removal, baclofen withdrawal is difficult to manage and life-threatening. Furthermore there is no consistency between dosing and severity of withdrawal. Case reports detail full baclofen withdrawal at dosages of 260 µg/day. OBJECTIVE: To demonstrate that in patients on stable IT baclofen for prolonged periods, externalizing a patient's original IT pump is a safe, effective way to wean IT doses. METHODS: Here, we describe a technique of continuing IT baclofen when urgent pump removal is needed. Specifically, we remove the infected pump. Then using a new or existing lumbar drain based on extent of infection, we reconnect the pump after cleaning with betadine and administer therapy externally during IT weaning. RESULTS: Hundred forty seven baclofen pumps were implanted or replaced within four years. Infections occurred in seven patients. We utilized this technique in five of seven patients. Mean IT dose at time of explant was 400.5 ± 285.3 µg/day. We titrated the dose by 20-50% per day based on clinical response over a mean of 6.2 ± 1.3 days. The catheter was removed at bedside once weaning was complete. No patients had any signs of withdrawal, excluding minimal spasticity increases while optimizing oral treatment. CONCLUSION: Here, we show preliminary evidence that an externalized IT pump is an effective means of weaning IT baclofen when infection of the pump occurs. This treatment strategy warrants further investigation, but appears to be a safe and effective. CONFLICT OF INTEREST: Dr. Pilitsis is a consultant for Medtronic, Boston Scientific, Nevro, Jazz Pharmaceuticals, Neurobridge Therapeutics, and Abbott and receives grant support from Medtronic, Boston Scientific, Abbott, Nevro, Jazz Pharmaceuticals, GE Global Research and NIH 1R01CA166379. She is medical advisor for Centauri and Karuna and has stock equity. Dr. Sukul receives consultant fees from Medtronic. Julia Prusik receives grant support from Jazz Pharmaceuticals.

Relationship of the sinus anatomy to surface landmarks is a function of the sinus size difference between the right and left side: Anatomical study based on CT angiography.

BACKGROUND: Several cadaveric studies demonstrate reliable localization of the transverse sinus and the transverse sigmoid junction (TSJ). These studies use the line drawn from the inion to the posterior root of the zygoma (IZ) and the asterion, respectively. We investigated how the size difference between the right and left transverse sinuses (TS) and sigmoid sinuses (SS) affected the accuracy of their respective superficial landmarks, particularly with regards to where this relationship may result in unsafe and/or complicated surgical access. METHODS: We utilized Vitrea software to render three-dimensional images based on computed tomographic angiography (CTA). We measured the relationship between the TS and SS to their respective superficial landmarks. RESULTS: We analyzed 50 patients in this study. The distal TS was found caudal to the inion-to-zygoma (IZ) line on average by 5.0 ± 4.3 mm on the right and 6.4 ± 9.3 mm on the left. The mid TS was found cranial on average 3.5 ± 5.7 mm on the right and 3.2 ± 6.0 mm cranial on the left to the superior nuchal line (SNL). The distance from the asterion to the SS was 11.5 ± 2.4 mm medial on the right and 12.1 ± 4.4 mm medial on the left. The average distance was greater on the left than the right when using the IZ landmark. This was directly proportional to the size difference of the sinuses (r2 = 0.15, P = 0.03). CONCLUSIONS: Statistically significant differences between the right and left TS and SS were seen in terms of size. This appeared to correlate nicely to the differences observed between the locations of the TSs' and their respective superficial landmarks.

Surgery for primary hyperparathyroidism: are the consensus guidelines being followed?

OBJECTIVE: To determine parathyroidectomy (PTx) rates in patients who satisfy the consensus guidelines for surgical treatment of primary hyperparathyroidism (PHPT). BACKGROUND: Surgery for PHPT is recommended for all symptomatic patients and select asymptomatic patients meeting established consensus criteria. Adherence to the consensus guidelines has not been examined systematically, because of inadequate information regarding patients managed nonoperatively. METHODS: All nonuremic patients with PHPT during the period 1995-2008 were identified using the Kaiser Permanente-Southern California laboratory database, encompassing 3.5 million individuals annually. Multivariate logistic regression was used to examine predictors of PTx. RESULTS: We found 3388 patients with PHPT, of whom 265 (8%) were symptomatic (nephrolithiasis). Nephrolithiasis was predictive of PTx (OR 2.94 vs asymptomatic), with 51% of symptomatic patients undergoing surgery. Among asymptomatic patients, the proportion meeting consensus criteria was 39% during the early period (1995-2002) and 51% during the late period (2003-2008). The PTx rate for these patients exceeded that for asymptomatic patients not meeting consensus criteria but remained low (early 44% vs 19%, P < 0.0001; late 39% vs 16%, P < 0.0001). The following individual criteria were predictive of PTx: calcium >11.5 mg/dL (OR 2.27), hypercalciuria (OR 3.28, P < 0.0001), and age < 50 years (OR 1.54, P < 0.0001). However, the absolute PTx rates associated with satisfaction of these criteria were in the 50% range. Bone density scores did not influence likelihood of PTx and renal impairment predicted against PTx (OR 0.35, P < 0.0001). CONCLUSIONS: The consensus guidelines regarding PHPT have not been followed in our study population. PTx appears to be underutilized in both asymptomatic and symptomatic patients.

Strategic impact of a new academic endocrine surgery program.

BACKGROUND: A minority of medical centers possess a dedicated endocrine surgery program. Here we assess the short-term impact of a new endocrine surgery program on institutional case volumes and financial endpoints. METHODS: We studied all endocrine procedures performed over a 5-year period spanning the inception of the endocrine surgery program at UCLA. Institutional and state-level data on patient geographic origin, discharges for endocrine diagnosis-related groups (DRGs), and hospital-side charges and costs were examined. RESULTS: Total endocrine case volume increased 112% (264 to 559 cases annually) over the study period. The relative increase was greater for parathyroid (56 to 196, 250%, P < 0.0001) and adrenal (11 to 31, 181%, P = 0.06) procedures compared to thyroid procedures (317 to 442, 39%). The endocrine case volume of nonspecialist surgeons remained stable over the study period. Growth in referrals arose from previously unrepresented zip codes and was associated with an increase in the mean distance traveled for care (2006, 44 miles vs. 2009, 92 miles, P < 0.01). In each DRG, UCLA attained the top market position within one year of the program's inception, corresponding to an overall 27% increase in regional market share. Total hospital charges for endocrine DRGs rose 161% to $14.7 million annually, while the cost of parathyroid surgery fell 34% (P < 0.001). CONCLUSIONS: The establishment of an academic endocrine surgery program can cause fundamental shifts in referral patterns within a competitive, densely populated metropolitan environment. Hospitals should consider the inclusion of an endocrine surgery program in strategic planning initiatives.

A selective, Bayesian approach to intraoperative PTH monitoring.

OBJECTIVE: To determine if the performance of intraoperative parathyroid hormone monitoring (IPM) can be optimized by limiting its application to patients with weak preoperative localization. BACKGROUND: The value of IPM during minimally invasive parathyroidectomy (MIP) has been questioned, particularly in cases with strong preoperative localization. We describe a novel, Bayesian strategy employing IPM in select patients with a high pretest probability of multiple gland disease (MGD). METHODS: We prospectively examined 361 consecutive patients undergoing surgery for primary hyperparathyroidism. All patients underwent sestamibi (MIBI) scanning and surgeon-performed ultrasound. Intraoperative PTH levels were only used for surgical decision-making in the MIBI-negative, ultrasound-positive patient subset. The following outcomes were analyzed: MGD rate, test performance, success rate, and operative time. RESULTS: Patients with any positive localization study (91%) were offered MIP. The success rate was 99%. The MGD rate was 3% in MIBI-positive patients and 36% in MIBI-negative patients (10% overall, P < 0.0001). MIBI and surgeon-performed ultrasound were equally sensitive (80% vs. 85%, NS). Among MIBI-negative patients, 71% of whom underwent MIP with IPM, an inadequate fall in the 10-minute postexcision PTH level was highly predictive of MGD, saving 10 failures while causing 1 inappropriate conversion to bilateral exploration (negative likelihood ratio, NLR 28.0). In contrast, among MIBI-positive patients, IPM could have saved 3 failures at the expense of 18 inappropriate conversions (NLR 9.9). IPM increased operative time from 34 to 60 minutes (P < 0.0001). CONCLUSION: IPM is more likely to guide the surgeon correctly when used only in MIBI-negative patients, who have a high pretest probability of MGD. This selective strategy maintains high success rates while limiting the frequently adverse impact that IPM carries when used indiscriminately.