Surgical Intervention is Associated with Improved Outcomes in Patients with Symptomatic Cervical Spine Tarlov Cysts: Results from a Prospective Cohort Study.

BACKGROUND: Tarlov cysts are known contributors to radiculopathy but are often misdiagnosed and mismanaged due to a paucity of information. This is particularly true of cervical spine Tarlov cysts because most attention has been focused on sacral cysts. In this study, we describe our longitudinal experience with patients who underwent surgery for cervical spine Tarlov cysts. We hypothesized that patients undergoing surgical treatment for cervical spine Tarlov cysts would report improvement following surgery. METHODS: We conducted a prospective study of patients who underwent surgical treatment for cervical Tarlov cysts between 2010 and 2021. The Short-Form 36-item survey (SF-36) was administered at the preoperative and follow-up visits. Repeated measures analyses were used to assess changes from preoperatively to postoperatively. RESULTS: A total of 37 patients with cervical spine cysts were included in the study. Follow-up data were available for 27 patients with a median follow-up of 1 year. Of the cohort, 97.3% were women, with an average age of 47.5 ± 10.3 years. Patients reported statistically significant improvement in 2 of the 4 SF-36 physical health domains (physical function, P< 0.001; and bodily pain, P < 0.001) and 2 of the 4 mental health domains (vitality/energy, P < 0.003; and social functioning, P = 0.007). Patients also reported less interference in work, education, and retirement activities at follow-up (P = 0.017). CONCLUSIONS: Our longitudinal series consisted of patients with symptomatic cervical spine Tarlov cysts, which, to the best of our knowledge, is the largest series described. Significant improvements in the SF-36 domains were documented, indicating these patients can be successfully treated surgically.

Nonoperative versus operative management of type II odontoid fracture in older adults: a systematic review and meta-analysis.

OBJECTIVE: Odontoid fractures are the most common fracture of the cervical spine in adults older than 65 years of age. Fracture management remains controversial, given the inherently increased surgical risks in older patients. The objective of this study was to compare fusion rates and outcomes between operative and nonoperative treatments of type II odontoid fractures in the older population. METHODS: A systematic literature review was performed to identify studies reporting the management of type II odontoid fractures in patients older than 65 years from database inception to September 2022. A meta-analysis was performed to compare rates of fusion, stable and unstable nonunion, mortality, and complication. RESULTS: Forty-six articles were included in the final review. There were 2822 patients included in the different studies (48.9% female, 51.1% male), with a mean ± SD age of 81.5 ± 3.6 years. Patients in the operative group were significantly younger than patients in the nonoperative group (81.5 ± 3.5 vs 83.4 ± 2.5 years, p < 0.001). The overall (operative and nonoperative patients) fusion rate was 52.9% (720/1361). The fusion rate was higher in patients who underwent surgery (74.3%) than in those who underwent nonoperative management (40.3%) (OR 4.27, 95% CI 3.36-5.44). The likelihood of stable or unstable nonunion was lower in patients who underwent surgery (OR 0.37, 95% CI 0.28-0.49 vs OR 0.32, 95% CI 0.22-0.47). Overall, 4.8% (46/964) of nonoperatively managed patients subsequently required surgery due to treatment failure. Patient mortality across all studies was 16.6% (452/2721), lower in the operative cohort (13.2%) than the nonoperative cohort (19.0%) (OR 0.64, 95% CI 0.52-0.80). Complications were more likely in patients who underwent surgery (26.0% vs 18.5%) (OR 1.55, 95% CI 1.23-1.95). Length of stay was also higher with surgery (13.6 ± 3.8 vs 8.1 ± 1.9 days, p < 0.001). CONCLUSIONS: Patients older than 65 years of age with type II odontoid fractures had higher fusion rates when treated with surgery and higher stable nonunion rates when managed nonoperatively. Complications and length of stay were higher in the surgical cohort. Mortality rates were lower in patients managed with surgery, but this phenomenon could be related to surgical selection bias. Fewer than 5% of patients who underwent nonoperative treatment required revision surgery due to treatment failure, suggesting that stable nonunion is an acceptable treatment goal.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) prior to interfacility transfer: Who might benefit in a statewide trauma system?

BACKGROUND: Rural trauma patients are often seen at lower-level trauma centers before transfer and have higher mortality than those seen initially at a Level 1 Trauma Center. This study aims to describe the potential for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to bridge this mortality gap. METHODS: We queried the Arizona Trauma Registry between 2014 and 2017 for hypotensive patients who were later transported to a level 1 center. REBOA candidates were identified as those with injuries consistent with major infra-diaphragmatic torso hemorrhage as the likely cause of death. RESULTS: Of 17,868 interfacility transfers during the study period, 333 met inclusion criteria and had sufficient data for evaluation. 26 of the 333 patients were identified as REBOA candidates. CONCLUSIONS: Our study suggests that REBOA may be an effective means to extend survivability to those severely injured trauma patients needing interfacility transfer to a higher level of care.

Pentobarbital coma for management of intracranial hypertension following traumatic brain injury: Lack of early response to treatment portends poor outcomes.

INTRODUCTION: Traumatic brain injury (TBI) results in the death of over 50,000 and the permanent disability of 80,000 individuals annually in the United States. Much of the permanent disability is the result of secondary brain injury from intracranial hypertension (ICH). Pentobarbital coma is often instituted following the failure of osmotic interventions and sedation to control intracranial pressure (ICP). The goal of this study was to evaluate the efficacy of pentobarbital coma with respect to ICP management and long-term functional outcome. METHODS: Traumatic brain injury patients who underwent pentobarbital coma at a level 1 trauma center between 2014 and 2021 were identified. Patient demographics, injury characteristics, Glasgow Coma Scale (GCS) scores, intracranial pressures (ICPs), and outcomes were obtained from the trauma registry as well as inpatient and outpatient medical records. The proportion of ICPs below 20 for each hospitalized patient-day was calculated. The primary outcome measured was GCS score at the last follow-up visit. RESULTS: 25 patients were identified, and the majority were male (n â€‹= â€‹23, 92%) with an average age of 30.0 years â€‹± â€‹12.9 and median injury severity score of 30 (21.5-33.5). ICPs were monitored for all patients with a median of 464 (326-1034) measurements. The average hospital stay was 16.9 days â€‹± â€‹11.5 and intensive care stay was 16.9 â€‹± â€‹10.8 days. 9 (36.0%) patients survived to hospital discharge. Mean follow-up time in months was 36.9 â€‹± â€‹28.0 (min-max 3-80). 7 of the 9 surviving patients presented as GCS 15 on follow-up and the remaining were both GCS 9. Patients presenting at last follow-up with GCS 15 had a significantly higher proportion of controlled ICPs throughout their hospitalization compared to patients who expired or with follow-up GCS <15 (GCS 15: 88% â€‹± â€‹10% vs. GCS <15 or dead: 68% â€‹± â€‹22%, P â€‹= â€‹0.006). A comparison of the daily proportion of controlled ICPs by group revealed negligible differences prior to pentobarbital initiation. Groups diverged nearly immediately upon pentobarbital coma initiation with a higher proportion of controlled ICPs for patients with follow-up GCS of 15. CONCLUSION: Patients that do not have an immediate response to pentobarbital coma therapy for ICH universally had poor outcomes. Alternative therapy or earlier palliation should be considered for such patients. In contrast, patients whose ICPs responded quickly to pentobarbital had excellent long-term outcomes.

A case series in individuals with multiple sclerosis using direct current electrical stimulation to inhibit spasticity and improve functional outcomes.

Background and Purpose: Multiple sclerosis (MS) has a high incidence of debilitating spasticity. Central Nervous System (CNS) intrafusal settings have an impact on spasticity level. Mechanoreceptors of the Peripheral Nervous System (PNS) communicate monosynaptically with the central nervous system (CNS). This case series assesses feasibility of multimodal treatment of individuals with MS using a direct current electrical stimulation (DC) to influence mechanoreceptors. Case Description and Intervention: Seven MS diagnosed participants with Expanded Disability Status Scale (EDSS) = 6.0-8.0 completed 18 visits over 6 weeks of using DC combined with neuromuscular reeducation. Design included pre-, post- outcome measures of EDSS, 12-item MS Walking Scale (MSWS-12), Range of Motion (ROM), Manual Muscle Testing (MMT), Modified Ashworth Test (MAT), Timed 25-Foot walk (T25WT), Timed Up and Go (TUG) and the Multiple Sclerosis Impact Scale-29 (MSIS-29). Outcome: 125 out of a possible 126 visits were completed, demonstrating a high level of tolerance. Individual results included trends towards improvement in spasticity and agonists. Discussion: This case series design of seven heterogenous subjects with MS is a low sample size for statistical analysis and should be considered a pilot. The study demonstrates a high level of feasibility and possible correlations to consider. Further research is warranted.

Complications associated with single-position prone lateral lumbar interbody fusion: a systematic review and pooled analysis.

OBJECTIVE: Lateral lumbar interbody fusion (LLIF) is a workhorse surgical approach for lumbar arthrodesis. There is growing interest in techniques for performing single-position surgery in which LLIF and pedicle screw fixation are performed with the patient in the prone position. Most studies of prone LLIF are of poor quality and without long-term follow-up; therefore, the complication profile related to this novel approach is not well known. The objective of this study was to perform a systematic review and pooled analysis to understand the safety profile of prone LLIF. METHODS: A systematic review of the literature and a pooled analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies reporting prone LLIF were assessed for inclusion. Studies not reporting complication rates were excluded. RESULTS: Ten studies meeting the inclusion criteria were analyzed. Overall, 286 patients were treated with prone LLIF across these studies, and a mean (SD) of 1.3 (0.2) levels per patient were treated. The 18 intraoperative complications reported included cage subsidence (3.8% [3/78]), anterior longitudinal ligament rupture (2.3% [5/215]), cage repositioning (2.1% [2/95]), segmental artery injury (2.0% [5/244]), aborted prone interbody placement (0.8% [2/244]), and durotomy (0.6% [1/156]). No major vascular or peritoneal injuries were reported. Sixty-eight postoperative complications occurred, including hip flexor weakness (17.8% [21/118]), thigh and groin sensory symptoms (13.3% [31/233]), revision surgery (3.8% [3/78]), wound infection (1.9% [3/156]), psoas hematoma (1.3% [2/156]), and motor neural injury (1.2% [2/166]). CONCLUSIONS: Single-position LLIF in the prone position appears to be a safe surgical approach with a low complication profile. Longer-term follow-up and prospective studies are needed to better characterize the long-term complication rates related to this approach.

Resilience Room Use and Its Effect on Distress Among Nurses and Allied Staff.

ABSTRACT: BACKGROUND: Nationwide nursing shortages have spurred nursing research on burnout and resiliency to better understand the emotional health of nurses and allied staff to retain talent. Our institution implemented resilience rooms in the neuroscience units of our hospital. The goal of this study was to evaluate the effects of resilience room use on emotional distress among staff. METHODS: Resilience rooms opened to staff in the neuroscience tower in January 2021. Entrances were electronically captured via badge readers. Upon exit, staff completed a survey containing items on demographics, burnout, and emotional distress. RESULTS: Resilience rooms were used 1988 times, and 396 surveys were completed. Rooms were most used by intensive care unit nurses (40.1% of entrances), followed by nurse leaders (28.8%). Staff with >10 years of experience accounted for 50.8% of uses. One-third reported moderate burnout, and 15.9% reported heavy or extreme burnout. Overall, emotional distress decreased by 49.4% from entrance to exit. The greatest decreases in distress were recorded by those with the lowest levels of burnout (72.5% decrease). CONCLUSION: Resilience room use was associated with significant decreases in emotional distress. The greatest decreases occurred with the lowest levels of burnout, suggesting that early engagement with resilience rooms is most beneficial.

Surgeon compassion may mitigate quality of life disparities associated with health literacy.

Objectives: Patients with health literacy (HL) disparities are less likely to comprehend hospital discharge instructions and less satisfied with physician communication. In this prospective cohort study, we sought to examine the interaction of HL, physician communication, and quality of life after hospital discharge among postoperative emergency surgery and trauma patients. Methods: Emergency surgery and trauma surgery patients were prospectively enrolled between December 2020 and December 2021 at an urban level 1 trauma center. Newest Vital Sign (NVS) instrument was used to measure HL during hospitalization. After discharge, patients were administered Revised Trauma Quality of Life (RT-QOL) and Interpersonal Processes of Care (IPC) instruments. An adjusted regression model was used to determine associations among NVS the emotional well-being subscale on the RT-QOL, and patient perception of physician compassion and respect on the IPC. Results: 94 patients completed all instruments. HL was proficient (high HL) in 59.6% and less than proficient (low HL) in 40.4%. HL was positively associated with RT-QOL emotional well-being, r(94)=0.212, p=0.040. However, higher rating of surgeon compassion and respect on IPC moderated the relationship between HL and emotional well-being such that patients with low HL and high perception of physician compassion and respect had similar emotional well-being as the high HL group (p=0.042). Conclusion: Favorable patient perception of surgeon compassion and respect was correlated with higher emotional well-being, independent of HL proficiency. Although the allocation of resources toward improving HL disparities remains warranted, improving patient perception of caregiver compassion during hospitalization may be a target of opportunity with respect to improving quality of life after hospital discharge. Level of evidence: Level III.

The Declining Use of Opioids at a Level 1 Trauma Center.

BACKGROUND: The epidemic of opioid-related overdose in the United States prompted a public health response that included implementation of opioid prescribing guidelines and restrictions. Such directives, however, were not applicable to hospitalized trauma patients. We hypothesized that although prescribing mandates did not apply to hospitalized trauma patients, inpatient opioid administration had nonetheless decreased over time. METHODS: Opioid administrations for each patient admitted to a level I trauma center between January 1, 2016 and July 31, 2020 were converted into oral morphine milligram equivalents (MMEs) and summed at the patient level to obtain a total amount of MME administered for each hospitalization. MME was natural log transformed to achieve a normal distribution. General linear models were then used to determine the average patient MME administered by year. Patients who were pregnant or mechanically ventilated during their hospitalization were excluded. RESULTS: Six thousand five hundred ninety-four patients were included in our analysis, of which 5037 (76.4%) were treated with opioids during their hospitalization (morphine 72.7%, oxycodone 9.6%, tramadol 10.2%, fentanyl 5.5%, and hydromorphone 2.1%). The percentage of patients administered an opioid decreased stepwise from 79.3% in 2016 to 71.4% in 2020 (P < .001). For patients administered opioids, a 28% decrease in average total MME from 2016 to 2020 (P < .001) was observed. When stratified by ISS (<9, 9-15, 16+), average total MME consistently trended downward over time. CONCLUSION: Our trauma center realized a stepwise reduction in opioid administration in the absence of rules or restrictions surrounding in-hospital opioid prescribing.

Perioperative Complication Profile of Skull Base Meningioma Resection in Older versus Younger Adult Patients.

Objectives To better understand the risk-benefit profile of skull base meningioma resection in older patients, we compared perioperative complications among older and younger patients. Design Present study is based on retrospective outcomes comparison. Setting The study was conducted at a single neurosurgery institute at a quaternary center. Participants All older (age ≥ 65 years) and younger (<65 years) adult patients treated with World Health Organization grade 1 skull base meningiomas (2008-2017). Main Outcome Measures Perioperative complications and patient functional status are the primary outcomes of this study. Results The analysis included 287 patients, 102 older and 185 younger, with a mean (standard deviation [SD]) age of 72 (5) years and 51 (9) years ( p < 0.01). Older patients were more likely to have hypertension ( p < 0.01) and type 2 diabetes mellitus ( p = 0.01) but other patient and tumor factors did not differ ( p ≥ 0.14). Postoperative medical complications were not significantly different in older versus younger patients (10.8 [11/102] vs. 4.3% [8/185]; p = 0.06) nor were postoperative surgical complications (13.7 [14/102] vs. 10.8% [20/185]; p = 0.46). Following anterior skull base meningioma resection, diabetes insipidus (DI) was more common in older versus younger patients (14 [5/37] vs. 2% [1/64]; p = 0.01). Among older patients, a decreasing preoperative Karnofsky performance status score independently predicted perioperative complications by logistic regression analysis ( p = 0.02). Permanent neurologic deficits were not significantly different in older versus younger patients (12.7 [13/102] vs. 10.3% [19/185]; p = 0.52). Conclusion The overall perioperative complication profile of older and younger patients was similar after skull base meningioma resection. Older patients were more likely to experience DI after anterior skull base meningioma resection. Decreasing functional status in older patients predicted perioperative complications.

Prospective Validation of a Quality-of-Life Measure for Women Undergoing Surgical Intervention for Symptomatic Sacral Tarlov Cysts: The Tarlov Cyst Quality of Life Scale.

BACKGROUND: The use of health-related quality-of-life scales has expanded into most areas of medicine. Established quality-of-life scales are used in several areas of neurosurgery, but none have been validated for use in patients with symptomatic Tarlov cysts. The majority of symptomatic Tarlov cysts are found in the sacral spinal canal of women. We, therefore, validated a site-specific quality-of-life measure for women with symptomatic sacral nerve root compression caused by Tarlov cysts. METHODS: Women undergoing surgical treatment for sacral Tarlov cysts at a single institution between 2017 and 2020 were enrolled in this prospective validation study. Participants were administered a 13-item version of the survey along with other validated quality-of-life measures preoperatively and at 3 months postoperatively. Psychometric analyses were performed to validate the measure. RESULTS: One hundred twelve patients met inclusion criteria and completed surveys preoperatively and at 3 months postoperatively. Patients' mean scale scores decreased significantly preoperatively to postoperatively, reflecting good discriminability (P < 0.001). Interitem correlations suggested 2 items were correlated at >0.80, which were dropped to create an 11-item scale. The internal consistency of the 11-item scale was 0.822. Concurrent validity was established by correlating scale scores with the Oswestry Disability Index (P < 0.001) and the physical function (P < 0.001) and pain (P < 0.001) subscales of the Short-Form 36 Survey. CONCLUSIONS: We prospectively validated a site-specific, health-related quality-of-life survey for women with symptomatic sacral Tarlov cysts. This measure will be useful in future studies to inform clinicians and researchers about the progression of Tarlov cysts and patient response to surgical treatment.

Can we really make catheter-associated urinary tract infections a never event? A level 1 trauma center's experience with prophylactic antibiotic bladder irrigation.

BACKGROUND: Hospital-acquired catheter-associated urinary tract infections (CAUTIs) are considered "never events" and are reportable to Centers for Medicare and Medicaid Services as a quality indicator. Despite protocols to determine appropriate removal of urinary catheters as soon as possible, severely injured trauma patients often require prolonged catheterization during ongoing resuscitation or develop retention requiring catheter replacement, exposing them to risk for CAUTI. We evaluated whether prophylactic antibiotic bladder irrigation reduces the incidence of CAUTI in critically ill trauma patients. METHODS: As a quality initiative, gentamicin bladder catheter irrigation (GBCI) was performed on a level 1 trauma center's patients at risk for CAUTI in 2021, defined by indwelling Foley catheterization for a minimum of 3 days. We then conducted a retrospective study using a comparison cohort of 2020 admissions as the control group. Catheter-associated urinary tract infection rates per 1,000 catheterized days were compared between these two groups. Patients with traumatic bladder injuries were excluded. RESULTS: Our cohort included 342 patients with a median hospitalization of 11 (7-17) days, Injury Severity Score of 17 (10-26), and 6 (4-11) days of catheterization. Eighty-six patients, catheterized for 939 at-risk days, received twice-daily GBCI compared with 256, catheterized for 2,114 at-risk days, who did not. Zero patients in the GBCI group versus nine patients in the control group developed CAUTI. The incidence of CAUTI in the GBCI group was significantly less than in the control group (0/1,000 vs. 4.3/1,000 catheterized days, p = 0.018). CONCLUSION: Prophylactic antibiotic bladder irrigation was associated with a zero incidence of CAUTI among trauma patients at risk for CAUTI. This practice holds promise as effective infection prophylaxis for such patients. The optimal duration and frequency of irrigation remain to be determined. LEVEL OF EVIDENCE: Therapeutic/care management, Level III.

Commonly performed pelvic binder modifications for femoral access may hinder binder efficacy.

BACKGROUND: Pelvic fractures are common and potentially life-threatening. Pelvic circumferential compression devices (PCCD) can temporize hemorrhage, but more invasive strategies that involve femoral access may be necessary for definitive treatment. The aim of our study was to evaluate the efficacy of PCCDs reducing open book pelvic fractures when utilizing commonly described modifications and placement adjustments that allow for access to the femoral vasculature. METHODS: Open book pelvic fractures were created in adult cadavers. Three commercially available PCCDs were used to reduce fractures. The binders were properly placed, moved caudally, or moved cranially and modified. Fracture reduction rates were then recorded. RESULTS: The pelvic fracture was completely reduced with every PCCD tested when properly placed. Reduction rates decreased with improper placement and modifications. CONCLUSION: Modifying PCCD placement to allow femoral access decreased the effectiveness of these devices Clinicians should be aware of this possibility when caring for critically injured trauma patients with pelvic fractures.

Adding to the story, did penetrating trauma really increase? changes in trauma patterns during the COVID-19 pandemic: A multi-institutional, multi-region investigation.

BACKGROUND: Results from single-region studies suggest that stay at home orders (SAHOs) had unforeseen consequences on the volume and patterns of traumatic injury during the initial months of the Coronavirus disease 2019 (COVID-19). The aim of this study was to describe, using a multi-regional approach, the effects of COVID-19 SAHOs on trauma volume and patterns of traumatic injury in the US. METHODS: A retrospective cohort study was performed at four verified Level I trauma centers spanning three geographical regions across the United States (US). The study period spanned from April 1, 2020 - July 31, 2020 including a month-matched 2019 cohort. Patients were categorized into pre-COVID-19 (PCOV19) and first COVID-19 surge (FCOV19S) cohorts. Patient demographic, injury, and outcome data were collected via Trauma Registry queries. Univariate and multivariate analyses were performed. RESULTS: A total 5,616 patients presented to participating study centers during the PCOV19 (2,916) and FCOV19S (2,700) study periods.  Blunt injury volume decreased (p = 0.006) due to a significant reduction in the number of motor vehicle collisions (MVCs) (p = 0.003). Penetrating trauma experienced a significant increase, 8% (246/2916) in 2019 to 11% (285/2,700) in 2020 (p = 0.007), which was associated with study site (p = 0.002), not SAHOs. Finally, study site was significantly associated with changes in nearly all injury mechanisms, whereas SAHOs accounted for observed decreases in calculated weekly averages of blunt injuries (p < 0.02) and MVCs (p = 0.003). CONCLUSION: Results of this study suggest that COVID-19 and initial SAHOs had variable consequences on patterns of traumatic injury, and that region-specific shifts in traumatic injury ensued during initial SAHOs. These results suggest that other factors, potentially socioeconomic or cultural, confound trauma volumes and types arising from SAHOs. Future analyses must consider how regional changes may be obscured with pooled cohorts, and focus on characterizing community-level changes to aid municipal preparation for future similar events.

Length of stay and trauma center finances: A disparity of payer source at a Level I trauma center.

BACKGROUND: In an effort to reduce costs, hospitals focus efforts on reducing length of stay (LOS) and often benchmark LOS against the geometric LOS (GMLOS) as predicted by the assigned diagnosis-related group (DRG) used by the Centers for Medicare and Medicaid Services. The objective of this cross-sectional study was to evaluate the impact of exceeding GMLOS on hospital profit/loss with respect to payer source. METHODS: Contribution margin for each insured patient admitted to a Level I trauma center between July 1, 2016, and June 30, 2019, was determined. Age, ethnicity, race, DRG weight, DRG version, injury severity, intensive care unit admission status, mechanical ventilation, payer, exceeding GMLOS, and the interaction between payer and exceeding the GMLOS were regressed on contribution margin to determine significant predictors of positive contribution margin. RESULTS: Among 2,449 insured trauma patients, the distribution of payers was Medicaid (54.6%), Medicare (24.0%), and commercial (21.4%). Thirty-five percent (n = 867) of patient LOS exceeded GMLOS. Exceeding GMLOS by 10 or more days was significantly more likely for Medicaid and Medicare patients in stepwise fashion (commercial, 2.7%; Medicaid, 4.5%; Medicare, 6.0%; p = 0.030). Median contribution margin was positive for commercially insured patients ($16,913) and negative for Medicaid (-$8,979) and Medicare (-$2,145) patients. Adjusted multivariate modeling demonstrated that when exceeding GMLOS, Medicare and Medicaid cases were less likely than commercial payers to have a positive contribution margin (p < 0.001 and p < 0.001). CONCLUSION: Government-insured patients, despite having a payer source, are a financial burden to a trauma center. Excess LOS among government insured patients, but not the commercially insured, exacerbates financial loss. A shift toward a greater proportion of government insured patients may result in a significant fiscal liability for a trauma center. LEVEL OF EVIDENCE: Economic and Value-Based Evaluation, Level III.

Evolution of postoperative pituitary adenoma resection cavities assessed by magnetic resonance imaging and implications regarding radiotherapy timing and modality.

PURPOSE: This study evaluates the temporal evolution of the spatial relationship between the pituitary adenoma transsphenoidal surgical cavity and the adjacent optic chiasm and discusses implications on timing and choice of radiotherapy modality. METHODS: This retrospective observational review analyzed factors that might influence the postoperative relationship between the surgical cavity and the optic chiasm, including tumor type, craniocaudal tumor and resection cavity dimensions, the preoperative distance between tumor and the optic chiasm, the presence of cavernous sinus invasion, and the choice of intraoperative packing material. Changes observed on magnetic resonance imaging in the preoperative, immediate (within 72 h), and delayed (≥3 months) postoperative periods were compared. RESULTS: Sixty-five patient histories were analyzed. Preoperatively, the pituitary adenoma was apposed to the optic chiasm in 43 patients (66%). Postoperatively, 34 patients (52%) in the immediate postoperative period and 54 patients (83%) in the delayed postoperative period had a distance ≥2 mm between the resection cavity and the optic chiasm. This distance provides a greater margin of safety with adjuvant radiosurgery. Preoperative tumor size showed a strong association with postoperative descent of the optic chiasm. CONCLUSIONS: Preoperative tumor size and degree of mass effect on the optic chiasm predict postoperative changes. In this study, the distance between the resection cavity and the optic chiasm was greater at ≥3 months postoperatively than in the immediate postoperative period, regardless of preoperative mass effect, indicating radiotherapy planning should be deferred to ≥3 months postoperatively when not precluded by aggressive histological characteristics that necessitate more immediate treatment. PRECIS: To investigate the temporal relationship between the postoperative sellar surgical cavity and the adjacent optic apparatus after transsphenoidal resection of pituitary adenomas and the implications for radiotherapy.

Saccular aneurysms in the post-Barrow Ruptured Aneurysm Trial era.

OBJECTIVE: The Barrow Ruptured Aneurysm Trial (BRAT) was a single-center trial that compared endovascular coiling to microsurgical clipping in patients treated for aneurysmal subarachnoid hemorrhage (aSAH). However, because patients in the BRAT were treated more than 15 years ago, and because there have been advances since then-particularly in endovascular techniques-the relevance of the BRAT today remains controversial. Some hypothesize that these technical advances may reduce retreatment rates for endovascular intervention. In this study, the authors analyzed data for the post-BRAT (PBRAT) era to compare microsurgical clipping with endovascular embolization (coiling and flow diverters) in the two time periods and to examine how the results of the original BRAT have influenced the practice of neurosurgeons at the study institution. METHODS: In this retrospective cohort study, the authors evaluated patients with saccular aSAHs who were treated at a single quaternary center from August 1, 2007, to July 31, 2019. The saccular aSAH diagnoses were confirmed by cerebrovascular experts. Patients were separated into two cohorts for comparison on the basis of having undergone microsurgery or endovascular intervention. The primary outcome analyzed for comparison was poor neurological outcome, defined as a modified Rankin Scale (mRS) score > 2. The secondary outcomes that were compared included retreatment rates for both therapies. RESULTS: Of the 1014 patients with aSAH during the study period, 798 (79%) were confirmed to have saccular aneurysms. Neurological outcomes at ≥ 1-year follow-up did not differ between patients treated with microsurgery (n = 451) and those who received endovascular (n = 347) treatment (p = 0.51). The number of retreatments was significantly higher among patients treated endovascularly (32/347, 9%) than among patients treated microsurgically (6/451, 1%) (p < 0.001). The retreatment rate after endovascular treatment was lower in the PBRAT era (9%) than in the BRAT (18%). CONCLUSIONS: Similar to results from the BRAT, results from the PBRAT era showed equivalent neurological outcomes and increased rates of retreatment among patients undergoing endovascular embolization compared with those undergoing microsurgery. However, the rate of retreatment after endovascular intervention was much lower in the PBRAT era than in the BRAT.

Early Psychiatric Consultation Is Associated With Decreased Cost and Length of Stay in the Patient Population at a Level I Trauma Center.

Introduction Psychiatric illness impacts nearly one-quarter of the US population. Few studies have evaluated the impact of psychiatric illness on in-hospital trauma patient care. In this study, we conducted a retrospective cohort study to evaluate hospital resource utilization for trauma patients with comorbid psychiatric illnesses. Methodology Trauma patients admitted to a level I center over a one-year period were included in the study. Patients were categorized into one of three groups: (1) no psychiatric history or in-hospital psychiatric service consultation; (2) psychiatric history but no psychiatric service consultation; and (3) psychiatric service consultation. Time to psychiatric service consultation was calculated and considered early if occurring on the day of or the day following admission. Patient demographics, outcomes, and resource utilization were compared between the three groups. Results A total of 1,807 patients were included in the study (n = 1,204, 66.6% no psychiatric condition; n = 508, 28.1% psychiatric condition without in-hospital psychiatric service consultation; and n = 95, 5.3% in-hospital psychiatric service consultation). Patients requiring psychiatric service consultation were the youngest (P < .001), with the highest injury severity (P = .024), the longest hospital length of stay (P < .001), and the highest median hospital cost (P < .001). Early psychiatric service consultation was associated with an average saving in-hospital length of stay of 2.9 days (P = .021) and an average hospital cost saving of $7,525 (P = .046). Conclusion One-third of our trauma population had an existing psychiatric diagnosis or required psychiatric service consultation. Resource utilization was higher for patients requiring consultation. Early consultation was associated with a savings of hospital length of stay and cost.

Evaluation and Acceptance of an Electric Toothbrush Designed for Dependent Patients.

INTRODUCTION: A key barrier to standardizing evidence-based oral health protocols for highly dependent patients is the lack of validated and accepted oral health products designed specifically for use by caregivers. This study compared preferences by users of a novel electric toothbrush and a manual toothbrush in a health care setting. METHODS: We prospectively enrolled health care providers as volunteers. Volunteer brushers completed simulated tooth brushing sessions of mock-intubated and non-intubated volunteer brushees with both toothbrushes. Volunteers rated different domains of toothbrush preference in an anonymous, optional survey. RESULTS: A total of 133 health care providers volunteered (123 brushers [providers brushing teeth] and 10 brushees [those having their teeth brushed]). The novel electric toothbrush received significantly higher positive ratings than the standard hospital-issue manual toothbrush in all domains that we surveyed: ease of use, thoroughness, safety, shape and size of the brush head, overall cleanliness, time requirements, and efficiency (p<0.001). Importantly, due to the integrated light and suction of this electric toothbrush, brushers completed more sessions without setting down the toothbrush with the electric toothbrush than with the manual toothbrush (75.4% vs 36.4%; p<0.001). CONCLUSIONS: Integrating a lighted electric brush with suction into the caregiver's armamentarium as an evidence-based tool is warranted and should be evaluated in terms of patient outcomes.

Anti-NMDA receptor encephalitis and brain atrophy in children and adults: A quantitative study.

PURPOSE: To determine whether brain atrophy was present in patients with anti-N-methyl-d-aspartate receptor encephalitis (anti-NMDARE) using qualitative and quantitative analyses of brain magnetic resonance imaging (MRI) and to explore clinical differences in patients with anti-NMDARE with or without brain atrophy. METHODS: A retrospective observational study encompassing the serologic, cerebrospinal fluid, and brain MRI data of 23 patients with anti-NMDARE was conducted. Median patient age was 14 years (interquartile range [IQR], 12 years). The cohort included 15 children (<18 years old) and 8 adults (≥18 years old). There were 6 male and 17 female patients. Imaging analysis involved 2 expert readers' observations of MRIs and automated volumetric quantification using NeuroQuant (CorTechs Labs, Inc.) software. RESULTS: Of 23 pediatric and adult patients, 11 patients had 14 brain MRIs that were quantitatively analyzed. Quantitative NeuroQuant volumetric analysis showed atrophy in 9 of 14 MRIs for 7 of 11 patients compared to age-controlled normative data. In these 9 MRIs, atrophy was present in the temporal lobes (n = 9), cerebral cortex (n = 3), and cerebellum (n = 3). Qualitative analysis of 59 MRIs (23 patients) revealed volume loss in 6 patients: 5 with global cerebral and temporal lobe volume loss and 1 with temporal lobe volume loss. No patient showed cerebellar volume loss on qualitative analysis. Mean length of stay in the intensive care unit was not significantly different for patients with or without quantitative volume loss (3.5 [5.2] vs 27.4 [23.4] days; p = 0.08). CONCLUSIONS: In this cohort of patients with anti-NMDARE, quantitative volumetric analysis showed brain atrophy, particularly affecting the temporal lobes, in 64% (7/11) of the patients. Qualitative analysis showed brain atrophy in 26% (6/23). These findings highlight the increased sensitivity of quantitative methods for volume loss detection. Larger studies are needed.