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1.
World Neurosurg ; 153: e147-e152, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34166830

RESUMO

BACKGROUND: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), and intracranial hemorrhage (ICH) may complicate the post-operative course of patients undergoing craniotomy. While prophylaxis with unfractionated heparin (UFH) has been shown to reduce VTE rates, twice-daily (BID) and three-times-daily (TID) UFH dosing regimens have not been compared in neurosurgical procedures. The objective of this study was to explore the association between UFH dosing regimen and rates of VTE and ICH in craniotomy patients. METHODS: A retrospective chart review was conducted for 159 patients at Northwestern University receiving 5000 units/0.5 mL UFH injections either BID (n = 132) or TID (n = 27). General linear regression models were run to predict rates of DVT, PE, and reoperation due to bleeding from UFH dosing regimen while controlling for age at surgery, sex, VTE history, craniotomy for tumor resection, surgery duration, length of stay, reoperation, infections, and IDH/MGMT mutations. RESULTS: Receiving UFH TID was significantly associated with a lower rate of PE when compared with receiving UFH BID (ß = -0.121, P = 0.044; TID rate = 0%, BID rate = 10.6%). UFH TID also showed a trend toward lower rates of DVT (ß = -0.0893, P = 0.295; TID rate = 18.5%, BID rate = 21.2%) when compared with UFH BID. UFH TID showed no significant difference in rate of reoperation for bleeding when compared to UFH BID (ß = -0.00623, P = 0.725; TID rate = 0%, BID rate = 0.8%). CONCLUSIONS: UFH TID dosing is associated with lower rates of PE when compared with BID dosing in patients undergoing craniotomy.


Assuntos
Anticoagulantes/administração & dosagem , Craniotomia , Heparina/administração & dosagem , Hemorragias Intracranianas/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Hemorragia Pós-Operatória/epidemiologia , Embolia Pulmonar/prevenção & controle , Trombose Venosa/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Encefálicas/cirurgia , Esquema de Medicação , Feminino , Glioblastoma/cirurgia , Hematoma/cirurgia , Humanos , Hemorragias Intracranianas/induzido quimicamente , Modelos Lineares , Masculino , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Hemorragia Pós-Operatória/induzido quimicamente , Embolia Pulmonar/epidemiologia , Reoperação , Estudos Retrospectivos , Trombose Venosa/epidemiologia , Adulto Jovem
2.
J Neurosci ; 41(18): 4036-4059, 2021 05 05.
Artigo em Inglês | MEDLINE | ID: mdl-33731450

RESUMO

We have previously established that PV+ neurons and Npas1+ neurons are distinct neuron classes in the external globus pallidus (GPe): they have different topographical, electrophysiological, circuit, and functional properties. Aside from Foxp2+ neurons, which are a unique subclass within the Npas1+ class, we lack driver lines that effectively capture other GPe neuron subclasses. In this study, we examined the utility of Kcng4-Cre, Npr3-Cre, and Npy2r-Cre mouse lines (both males and females) for the delineation of GPe neuron subtypes. By using these novel driver lines, we have provided the most exhaustive investigation of electrophysiological studies of GPe neuron subtypes to date. Corroborating our prior studies, GPe neurons can be divided into two statistically distinct clusters that map onto PV+ and Npas1+ classes. By combining optogenetics and machine learning-based tracking, we showed that optogenetic perturbation of GPe neuron subtypes generated unique behavioral structures. Our findings further highlighted the dissociable roles of GPe neurons in regulating movement and anxiety-like behavior. We concluded that Npr3+ neurons and Kcng4+ neurons are distinct subclasses of Npas1+ neurons and PV+ neurons, respectively. Finally, by examining local collateral connectivity, we inferred the circuit mechanisms involved in the motor patterns observed with optogenetic perturbations. In summary, by identifying mouse lines that allow for manipulations of GPe neuron subtypes, we created new opportunities for interrogations of cellular and circuit substrates that can be important for motor function and dysfunction.SIGNIFICANCE STATEMENT Within the basal ganglia, the external globus pallidus (GPe) has long been recognized for its involvement in motor control. However, we lacked an understanding of precisely how movement is controlled at the GPe level as a result of its cellular complexity. In this study, by using transgenic and cell-specific approaches, we showed that genetically-defined GPe neuron subtypes have distinct roles in regulating motor patterns. In addition, the in vivo contributions of these neuron subtypes are in part shaped by the local, inhibitory connections within the GPe. In sum, we have established the foundation for future investigations of motor function and disease pathophysiology.


Assuntos
Globo Pálido/citologia , Globo Pálido/fisiologia , Atividade Motora/fisiologia , Neurônios/fisiologia , Animais , Ansiedade/psicologia , Fatores de Transcrição Hélice-Alça-Hélice Básicos/genética , Comportamento Animal , Fenômenos Biomecânicos , Fenômenos Eletrofisiológicos , Feminino , Aprendizado de Máquina , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Rede Nervosa/citologia , Rede Nervosa/fisiologia , Proteínas do Tecido Nervoso/genética , Optogenética , Canais de Potássio de Abertura Dependente da Tensão da Membrana/genética , Receptores do Fator Natriurético Atrial/genética
3.
Clin Neurol Neurosurg ; 199: 106280, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33080428

RESUMO

BACKGROUND AND OBJECTIVE: Unilateral subaxial non-subluxed facet fractures (USNSFF) are a pathology seen in traumatic events such as motor vehicle accidents. Management involves either rigid collar bracing or surgical intervention. There currently is no consensus on the treatment of these injuries; this review aims to examine the extant data for recommendations as to which treatment is more effective. METHODS: MEDLINE, Scopus, and the Cochrane trial register were all searched on January 16, 2020, comparing outcomes for surgical and conservative therapy for USNSFF. The meta-analysis examined rates of treatment failure (need for subsequent operative management) in conservative versus surgical management. The meta-analysis was performed using a random effects model, with visualization in forest and L'Abbé plots. RESULTS: We identified six retrospective studies describing 270 patients, with three studies describing 137 patients used in the meta-analysis. Overall, a surgical success rate of 97.7 % and a non-operative success rate of 79.7 % was observed. A random effects model risk ratio of 1.66 (95 % CI: 0.61-4.52) was obtained, suggesting efficacy of surgical management over conservative management. CONCLUSION: The need for surgical intervention subsequent to initial management in the treatment of USNSFF was found to be lower in surgical treatment in contrast to conservative management. However, the studies that were included in the meta-analysis had patient cohorts with much higher rates of neurological deficit and ligamentous injury on presentation, indicating that these may be prognostic indicators of conservative management failure. Furthermore, those that did fail conservative management did not develop severely debilitating conditions. Accordingly, conservative treatment is generally sufficient as a first step in a majority of cases of USNSFF lacking neurological deficit or ligamentous involvement.


Assuntos
Tratamento Conservador/métodos , Fixação de Fratura/métodos , Fraturas da Coluna Vertebral/cirurgia , Articulação Zigapofisária/cirurgia , Tratamento Conservador/tendências , Fixação de Fratura/tendências , Humanos , Estudos Retrospectivos , Fraturas da Coluna Vertebral/diagnóstico por imagem , Fraturas da Coluna Vertebral/terapia , Articulação Zigapofisária/diagnóstico por imagem
4.
J Neurosurg ; 134(5): 1610-1617, 2020 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-32442979

RESUMO

OBJECTIVE: Intraoperative stimulation has emerged as a crucial adjunct in neurosurgical oncology, aiding maximal tumor resection while preserving sensorimotor and language function. Despite increasing use in clinical practice of this stimulation, there are limited data on both intraoperative seizure (IS) frequency and the presence of afterdischarges (ADs) in patients undergoing such procedures. The objective of this study was to determine risk factors for IS or ADs, and to determine the clinical consequences of these intraoperative events. METHODS: A retrospective chart review was performed for patients undergoing awake craniotomy (both first time and repeat) at a single institution from 2013 to 2018. Hypothesized risk factors for ADs/ISs in patients were evaluated for their effect on ADs and ISs, including tumor location, tumor grade (I-IV), genetic markers (isocitrate dehydrogenase 1/2, O 6-methylguanine-DNA methyltransferase [MGMT] promoter methylation, chromosome 1p/19q codeletion), tumor volume, preoperative seizure status (yes/no), and dosage of preoperative antiepileptic drugs for each patient. Clinical outcomes assessed in patients with IS or ADs were duration of surgery, length of stay, presence of perioperative deficits, and postoperative seizures. Chi-square analysis was performed for binary categorical variables, and a Student t-test was used to assess continuous variables. RESULTS: A total of 229 consecutive patients were included in the analysis. Thirty-five patients (15%) experienced ISs. Thirteen (37%) of these 35 patients had experienced seizures that were appreciated clinically and noted on electrocorticography simultaneously, while 8 patients (23%) experienced ISs that were electrographic alone (no obvious clinical change). MGMT promoter methylation was associated with an increased prevalence of ISs (OR 3.3, 95% CI 1.2-7.8, p = 0.02). Forty patients (18%) experienced ADs. Twenty-three percent of patients (9/40) with ISs had ADs prior to their seizure, although ISs and ADs were not statistically associated (p = 0.16). The presence of ADs appeared to be correlated with a shorter length of stay (5.1 ± 2.6 vs 6.1 ± 3.7 days, p = 0.037). Of the clinical features assessed, none were found to be predictive of ADs. Neither IS nor AD, or the presence of either IS or AD (65/229 patients), was a predictor for increased length of stay, presence of perioperative deficits, or postoperative seizures. CONCLUSIONS: ISs and ADs, while commonly observed during intraoperative stimulation for brain mapping, do not negatively affect patient outcomes.


Assuntos
Mapeamento Encefálico/efeitos adversos , Craniotomia , Eletrocorticografia/efeitos adversos , Complicações Intraoperatórias/etiologia , Monitorização Intraoperatória/efeitos adversos , Convulsões/etiologia , Adulto , Biomarcadores Tumorais , Mapeamento Encefálico/métodos , Neoplasias Encefálicas/genética , Neoplasias Encefálicas/fisiopatologia , Neoplasias Encefálicas/cirurgia , Metilação de DNA , Metilases de Modificação do DNA/genética , Enzimas Reparadoras do DNA/genética , Feminino , Humanos , Complicações Intraoperatórias/fisiopatologia , Isocitrato Desidrogenase/genética , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Regiões Promotoras Genéticas , Estudos Retrospectivos , Fatores de Risco , Convulsões/fisiopatologia , Carga Tumoral , Proteínas Supressoras de Tumor/genética , Vigília
5.
Neurosurgery ; 86(6): E490-E507, 2020 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-32271911

RESUMO

BACKGROUND: Prescription opioid use and opioid-related deaths have become an epidemic in the United States, leading to devastating economic and health ramifications. Opioids are the most commonly prescribed drug class to treat low back pain, despite the limited body of evidence supporting their efficacy. Furthermore, preoperative opioid use prior to spine surgery has been reported to range from 20% to over 70%, with nearly 20% of this population being opioid dependent. OBJECTIVE: To review the medical literature on the effect of preoperative opioid use in outcomes in spine surgery. METHODS: We reviewed manuscripts published prior to February 1, 2019, exploring the effect of preoperative opioid use on outcomes in spine surgery. We identified 45 articles that analyzed independently the effect of preoperative opioid use on outcomes (n = 32 lumbar surgery, n = 19 cervical surgery, n = 7 spinal deformity, n = 5 "other"). RESULTS: Preoperative opioid use is overwhelmingly associated with negative surgical and functional outcomes, including postoperative opioid use, hospitalization duration, healthcare costs, risk of surgical revision, and several other negative outcomes. CONCLUSION: There is an urgent and unmet need to find and apply extensive perioperative solutions to combat opioid use, particularly in patients undergoing spine surgery. Further investigations are necessary to determine the optimal method to treat such patients and to develop opioid-combative strategies in patients undergoing spine surgery.


Assuntos
Analgésicos Opioides/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Dor Pós-Operatória/epidemiologia , Cuidados Pré-Operatórios/efeitos adversos , Doenças da Coluna Vertebral/cirurgia , Analgésicos Opioides/administração & dosagem , Humanos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Cuidados Pré-Operatórios/métodos , Reoperação , Doenças da Coluna Vertebral/tratamento farmacológico , Resultado do Tratamento
6.
World Neurosurg ; 139: e159-e165, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32272269

RESUMO

OBJECTIVE: Acute subdural hematoma (aSDH) is a common pathology encountered in neurosurgery. Although most cases are associated with trauma and injuries to draining veins, traumatic aSDH from injury to arteries or spontaneous aSDH because of a ruptured intracranial aneurysm can occur. For some patients without a clear clinical history, it can be difficult to distinguish between these etiologies purely based on radiography. The objective of this research was to describe a case series in which imaging was suggestive of the presence of distal cortical intracranial aneurysm associated with aSDH, but operative management demonstrated no evidence of aneurysm. METHODS: We retrospectively reviewed 2 patients known to have aSDH with suspicion for associated aneurysm between May 2019 and September 2019 at our institution. Data collected included demographic, clinical, and operative course, including age, gender, past medical history, presenting symptoms, and pre and postoperative imaging. RESULTS: In 2 patients presenting with aSDH with preoperative radiographic imaging suggesting distal middle cerebral artery aneurysms, surgical exploration revealed no aneurysm. In both cases, noniatrogenic active arterial bleeding from an injured cortical middle cerebral artery branch was identified. CONCLUSIONS: Although there are prior reports of arterial aSDH, to our knowledge, this is the first to describe the radiographic "ghost aneurysm" sign. It is important for clinicians to be aware of this potential misleading radiographic sign, which indicates active extravasation into a spherical cast of clot.


Assuntos
Hematoma Subdural Agudo/diagnóstico por imagem , Hematoma Subdural Agudo/etiologia , Artéria Cerebral Média/lesões , Idoso , Idoso de 80 Anos ou mais , Angiografia Cerebral/métodos , Angiografia por Tomografia Computadorizada/métodos , Hematoma Subdural Agudo/cirurgia , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Masculino , Artéria Cerebral Média/diagnóstico por imagem , Estudos Retrospectivos
7.
NPJ Digit Med ; 3: 29, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32195364

RESUMO

Hydrocephalus is a common disorder caused by the buildup of cerebrospinal fluid (CSF) in the brain. Treatment typically involves the surgical implantation of a pressure-regulated silicone tube assembly, known as a shunt. Unfortunately, shunts have extremely high failure rates and diagnosing shunt malfunction is challenging due to a combination of vague symptoms and a lack of a convenient means to monitor flow. Here, we introduce a wireless, wearable device that enables precise measurements of CSF flow, continuously or intermittently, in hospitals, laboratories or even in home settings. The technology exploits measurements of thermal transport through near-surface layers of skin to assess flow, with a soft, flexible, and skin-conformal device that can be constructed using commercially available components. Systematic benchtop studies and numerical simulations highlight all of the key considerations. Measurements on 7 patients establish high levels of functionality, with data that reveal time dependent changes in flow associated with positional and inertial effects on the body. Taken together, the results suggest a significant advance in monitoring capabilities for patients with shunted hydrocephalus, with potential for practical use across a range of settings and circumstances, and additional utility for research purposes in studies of CSF hydrodynamics.

8.
J Neurosci ; 40(4): 743-768, 2020 01 22.
Artigo em Inglês | MEDLINE | ID: mdl-31811030

RESUMO

Within the basal ganglia circuit, the external globus pallidus (GPe) is critically involved in motor control. Aside from Foxp2+ neurons and ChAT+ neurons that have been established as unique neuron types, there is little consensus on the classification of GPe neurons. Properties of the remaining neuron types are poorly defined. In this study, we leverage new mouse lines, viral tools, and molecular markers to better define GPe neuron subtypes. We found that Sox6 represents a novel, defining marker for GPe neuron subtypes. Lhx6+ neurons that lack the expression of Sox6 were devoid of both parvalbumin and Npas1. This result confirms previous assertions of the existence of a unique Lhx6+ population. Neurons that arise from the Dbx1+ lineage were similarly abundant in the GPe and displayed a heterogeneous makeup. Importantly, tracing experiments revealed that Npas1+-Nkx2.1+ neurons represent the principal noncholinergic, cortically-projecting neurons. In other words, they form the pallido-cortical arm of the cortico-pallido-cortical loop. Our data further show that pyramidal-tract neurons in the cortex collateralized within the GPe, forming a closed-loop system between the two brain structures. Overall, our findings reconcile some of the discrepancies that arose from differences in techniques or the reliance on preexisting tools. Although spatial distribution and electrophysiological properties of GPe neurons reaffirm the diversification of GPe subtypes, statistical analyses strongly support the notion that these neuron subtypes can be categorized under the two principal neuron classes: PV+ neurons and Npas1+ neurons.SIGNIFICANCE STATEMENT The poor understanding of the neuronal composition in the external globus pallidus (GPe) undermines our ability to interrogate its precise behavioral and disease involvements. In this study, 12 different genetic crosses were used, hundreds of neurons were electrophysiologically characterized, and >100,000 neurons were histologically- and/or anatomically-profiled. Our current study further establishes the segregation of GPe neuron classes and illustrates the complexity of GPe neurons in adult mice. Our results support the idea that Npas1+-Nkx2.1+ neurons are a distinct GPe neuron subclass. By providing a detailed analysis of the organization of the cortico-pallidal-cortical projection, our findings establish the cellular and circuit substrates that can be important for motor function and dysfunction.


Assuntos
Fatores de Transcrição Hélice-Alça-Hélice Básicos/metabolismo , Córtex Cerebral/metabolismo , Globo Pálido/metabolismo , Proteínas do Tecido Nervoso/metabolismo , Neurônios/metabolismo , Fator Nuclear 1 de Tireoide/metabolismo , Animais , Fatores de Transcrição Hélice-Alça-Hélice Básicos/genética , Camundongos , Camundongos Transgênicos , Proteínas do Tecido Nervoso/genética , Vias Neurais/metabolismo , Fator Nuclear 1 de Tireoide/genética
9.
J Clin Neurosci ; 69: 143-148, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31427233

RESUMO

Medical student (MS) observation and assistance in the operating room (OR) is a critical component of medical education. Though participation in the operating room has many benefits to the medical student, the potential cost of these experiences to the patients must be taken into account. Other studies have shown differences in outcomes with resident involvement, but the effect of medical students in the OR has been poorly understood. The objective of this study was to understand how medical students and residents impacted surgical outcomes in posterior spinal fusions, anterior cervical discectomy and fusions (ACDFs), and lumbar discectomies. We conducted a retrospective study of patients undergoing posterior spinal fusions, ACDFs, and lumbar discectomies over 15 years. There were 6485 patients met the inclusion criteria of either undergoing a posterior fusion, ACDF or lumbar discectomy (1250 posterior fusion, 1381 ACDF, 3854 lumbar discectomies). Overall, little difference was observed when a medical student was present for surgical outcomes including length of stay, infection, and readmission. For ACDFs, having a medical student present had a significantly longer procedure durations (OR = 1.612, p = 0.001) than cases without. Besides slightly longer operative time (in posterior fusions), there were no major differences in outcomes when a medical student was present in the OR.


Assuntos
Discotomia/educação , Educação Médica , Duração da Cirurgia , Fusão Vertebral/educação , Adulto , Vértebras Cervicais/cirurgia , Discotomia/métodos , Educação Médica/economia , Educação Médica/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fusão Vertebral/métodos , Estudantes de Medicina , Resultado do Tratamento , Adulto Jovem
10.
Sci Transl Med ; 10(465)2018 10 31.
Artigo em Inglês | MEDLINE | ID: mdl-30381410

RESUMO

Hydrocephalus is a common and costly neurological condition caused by the overproduction and/or impaired resorption of cerebrospinal fluid (CSF). The current standard of care, ventricular catheters (shunts), is prone to failure, which can result in nonspecific symptoms such as headaches, dizziness, and nausea. Current diagnostic tools for shunt failure such as computed tomography (CT), magnetic resonance imaging (MRI), radionuclide shunt patency studies (RSPSs), and ice pack-mediated thermodilution have disadvantages including high cost, poor accuracy, inconvenience, and safety concerns. Here, we developed and tested a noninvasive, skin-mounted, wearable measurement platform that incorporates arrays of thermal sensors and actuators for precise, continuous, or intermittent measurements of flow through subdermal shunts, without the drawbacks of other methods. Systematic theoretical and experimental benchtop studies demonstrate high performance across a range of practical operating conditions. Advanced electronics designs serve as the basis of a wireless embodiment for continuous monitoring based on rechargeable batteries and data transmission using Bluetooth protocols. Clinical studies involving five patients validate the sensor's ability to detect the presence of CSF flow (P = 0.012) and further distinguish between baseline flow, diminished flow, and distal shunt failure. Last, we demonstrate processing algorithms to translate measured data into quantitative flow rate. The sensor designs, fabrication schemes, wireless architectures, and patient trials reported here represent an advance in hydrocephalus diagnostics with ability to visualize flow in a simple, user-friendly mode, accessible to the physician and patient alike.


Assuntos
Derivações do Líquido Cefalorraquidiano , Epiderme/fisiologia , Hidrocefalia/fisiopatologia , Dispositivos Eletrônicos Vestíveis , Tecnologia sem Fio , Humanos , Reologia , Incerteza
11.
Am J Med Qual ; 32(1): 80-86, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-26646282

RESUMO

The purpose of this study was to use fault tree analysis to evaluate the adequacy of quality reporting programs in identifying root causes of postoperative bloodstream infection (BSI). A systematic review of the literature was used to construct a fault tree to evaluate 3 postoperative BSI reporting programs: National Surgical Quality Improvement Program (NSQIP), Centers for Medicare and Medicaid Services (CMS), and The Joint Commission (JC). The literature review revealed 699 eligible publications, 90 of which were used to create the fault tree containing 105 faults. A total of 14 identified faults are currently mandated for reporting to NSQIP, 5 to CMS, and 3 to JC; 2 or more programs require 4 identified faults. The fault tree identifies numerous contributing faults to postoperative BSI and reveals substantial variation in the requirements and ability of national quality data reporting programs to capture these potential faults. Efforts to prevent postoperative BSI require more comprehensive data collection to identify the root causes and develop high-reliability improvement strategies.


Assuntos
Bacteriemia/etiologia , Infecção Hospitalar/etiologia , Complicações Pós-Operatórias/etiologia , Melhoria de Qualidade/organização & administração , Humanos , Indicadores de Qualidade em Assistência à Saúde , Reprodutibilidade dos Testes , Estados Unidos
12.
World Neurosurg ; 94: 255-260, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27423195

RESUMO

BACKGROUND: Minimally invasive transforaminal lumbar interbody fusion (TLIF) has undergone significant evolution since its conception as a fusion technique to treat lumbar spondylosis. Minimally invasive TLIF is commonly performed using intraoperative two-dimensional fluoroscopic x-rays. However, intraoperative computed tomography (CT)-based navigation during minimally invasive TLIF is gaining popularity for improvements in visualizing anatomy and reducing intraoperative radiation to surgeons and operating room staff. This is the first study to compare clinical outcomes and cost between these 2 imaging techniques during minimally invasive TILF. METHODS: For comparison, 28 patients who underwent single-level minimally invasive TLIF using fluoroscopy were matched to 28 patients undergoing single-level minimally invasive TLIF using CT navigation based on race, sex, age, smoking status, payer type, and medical comorbidities (Charlson Comorbidity Index). The minimum follow-up time was 6 months. The 2 groups were compared in regard to clinical outcomes and hospital reimbursement from the payer perspective. RESULTS: Average surgery time, anesthesia time, and hospital length of stay were similar for both groups, but average estimated blood loss was lower in the fluoroscopy group compared with the CT navigation group (154 mL vs. 262 mL; P = 0.016). Oswestry Disability Index, back visual analog scale, and leg visual analog scale scores similarly improved in both groups (P > 0.05) at 6-month follow-up. Cost analysis showed that average hospital payments were similar in the fluoroscopy versus the CT navigation groups ($32,347 vs. $32,656; P = 0.925) as well as payments for the operating room (P = 0.868). CONCLUSIONS: Single minimally invasive TLIF performed with fluoroscopy versus CT navigation showed similar clinical outcomes and cost at 6 months.


Assuntos
Fluoroscopia/economia , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Fusão Vertebral/economia , Espondilose/economia , Espondilose/cirurgia , Cirurgia Assistida por Computador/economia , Tomografia Computadorizada por Raios X/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Prevalência , Espondilose/epidemiologia , Resultado do Tratamento , Estados Unidos/epidemiologia
13.
Case Rep Neurol Med ; 2016: 8371697, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26885420

RESUMO

Background. Purely ectopic pituitary adenomas are exceedingly rare. Here we report on a patient that presented with an incidental clival mass thought to be a chordoma. Endonasal resection, tumor pathology, and endocrinology workup revealed a prolactinoma. Case Presentation. A 41-year-old male presented with an incidental clival lesion presumed to be a chordoma. On MRI it involved the entire clivus, extended laterally to the petroclival junction, and invaded the cavernous sinuses bilaterally, encasing both internal carotid arteries, without direct extension into the sella. Intraoperatively, it was clear that the tumor originated from the clivus and that the sellar dura was completely intact. Frozen-section pathology was consistent with a pituitary adenoma. Immunostaining was positive for synaptophysin and prolactin with a low Ki-67 index, suggestive of a prolactinoma. Additional immunohistochemical stains seen in chordomas (EMA, S100, and Brachyury) and other metastatic tumors were negative. A postoperative endocrine workup revealed an elevated serum prolactin of 881.3 ng/mL (normal < 20). Conclusions. In conclusion, it is crucial to maintain an extensive differential diagnosis when evaluating a patient with a clival lesion. Ectopic clival pituitary adenomas, although rare, may warrant an endocrinological workup preoperatively as the majority may respond to medical treatment.

14.
BMJ Qual Saf ; 25(1): 46-55, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26424762

RESUMO

BACKGROUND: Video recorded and in-person observations are methods of quality assessment and monitoring that have been employed in high risk industries. In the medical field, observations have been used to evaluate the quality and safety of various clinical processes. This review summarises studies utilising video recorded or in-person observations for assessing clinician performance in medicine and surgery. METHODS: A search of MEDLINE (PubMed) was conducted using a combination of medical subject headings (MeSH) terms. Articles were included if they described the use of in-person or video recorded observations to assess clinician practices in three categories: (1) teamwork and communication between clinicians; (2) errors and weaknesses in practice; and (3) compliance and adherence to interventions or guidelines. RESULTS: The initial search criteria returned 3215 studies, 223 of which were identified for full text review. A total of 69 studies were included in the final set of literature. Observations were most commonly used in data dense and high risk environments, such as the emergency department or operating room. The most common use was for assessing teamwork and communication factors. CONCLUSIONS: Observations are useful for the improvement of healthcare delivery through the identification of clinician lapses and weaknesses that affect quality and safety. Limitations of observations include the Hawthorne effect and the necessity of trained observers to capture and analyse the notes or videos. The comprehensive, subtle and sensitive information observations provided can supplement traditional quality assessment methods and inform targeted interventions to improve patient safety and the quality of care.


Assuntos
Administração Hospitalar , Qualidade da Assistência à Saúde/organização & administração , Análise e Desempenho de Tarefas , Competência Clínica , Comunicação , Processos Grupais , Fidelidade a Diretrizes , Humanos , Estudos Observacionais como Assunto , Equipe de Assistência ao Paciente , Guias de Prática Clínica como Assunto , Qualidade da Assistência à Saúde/normas , Gravação em Vídeo
15.
J Surg Res ; 193(1): 88-94, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25277361

RESUMO

Wrong-site surgery (WSS) is a rare event that occurs to hundreds of patients each year. Despite national implementation of the Universal Protocol over the past decade, development of effective interventions remains a challenge. We performed a systematic review of the literature reporting root causes of WSS and used the results to perform a fault tree analysis to assess the reliability of the system in preventing WSS and identifying high-priority targets for interventions aimed at reducing WSS. Process components where a single error could result in WSS were labeled with OR gates; process aspects reinforced by verification were labeled with AND gates. The overall redundancy of the system was evaluated based on prevalence of AND gates and OR gates. In total, 37 studies described risk factors for WSS. The fault tree contains 35 faults, most of which fall into five main categories. Despite the Universal Protocol mandating patient verification, surgical site signing, and a brief time-out, a large proportion of the process relies on human transcription and verification. Fault tree analysis provides a standardized perspective of errors or faults within the system of surgical scheduling and site confirmation. It can be adapted by institutions or specialties to lead to more targeted interventions to increase redundancy and reliability within the preoperative process.


Assuntos
Procedimentos Clínicos/normas , Cuidados Intraoperatórios/normas , Erros Médicos/prevenção & controle , Avaliação de Processos e Resultados em Cuidados de Saúde/métodos , Cuidados Pré-Operatórios/normas , Especialidades Cirúrgicas/normas , Agendamento de Consultas , Procedimentos Clínicos/estatística & dados numéricos , Humanos , Cuidados Intraoperatórios/estatística & dados numéricos , Erros Médicos/estatística & dados numéricos , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Cuidados Pré-Operatórios/estatística & dados numéricos , Probabilidade , Reprodutibilidade dos Testes , Medição de Risco , Especialidades Cirúrgicas/estatística & dados numéricos
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