Population analysis of ischemic stroke burden and risk factors in the United States in the pre- and post-mechanical thrombectomy eras.

OBJECTIVES: To provide an updated analysis of the burden of ischemic stroke in the United States. MATERIALS AND METHODS: Using the Global Burden of Disease database, we estimated age-standardized, population-adjusted rates of incidence, prevalence, mortality, and disability-adjusted life years from 2010 to 2019, with regional comparisons. Deaths and disability-adjusted life years were compared in 2010-2014 and 2015-2019 to assess the potential effect of increased mechanical thrombectomy use. The attributable, disability-adjusted life years for twenty risk factors were estimated, ranked, and trended. RESULTS: Incident ischemic strokes decreased by 11.4 % across the study period from 65.7 (55.9-77.3) to 58.2 (49.0-69.5) per 100,000. Prevalence (-8.2 %), mortality (-1.9 %), and disability-adjusted life years (-4.4 %) all declined. All regions showed reductions in all burden measures, with the South consistently having the highest burden yet the largest reduction in incidence (-12.6 %) and prevalence (-10.5 %). Deaths (p < 0.0001) and DALYs (p < 0.0001) significantly differed between the pre- and post-mechanical thrombectomy eras. Total attributable disability-adjusted life years for all risk factors decreased from 304.7 (258.5-353.2) in 2010 to 288.9 (242.2-337.2) in 2019. In 2019, the risk factors with the most disability-adjusted life years were hypertension, hyperglycemia, and obesity with no state-based differences. Across the study period, disability-adjusted life years attributable to leading risk factors decreased among men but decreased less or increased among women. CONCLUSIONS: The burden of ischemic stroke decreased during the study period. Declines in deaths and disability-adjusted life years suggest a mitigating impact of mechanical thrombectomy. While disability-adjusted life years attributable to leading risk factors decreased, sex-based disparities were observed.

The epidemiology of crib-related head injuries: A ten-year nationwide analysis.

INTRODUCTION: Falls from cribs resulting in head injury are understudied and poorly characterized. The purpose of this study was to advance current understanding of the prevalence, descriptive characteristics of injury victims, and the types of crib fall-related head injuries (CFHI) using queried patient cases from the National Electronic Injury Surveillance System (NEISS) database. METHODS: Using the US Consumer Product Safety Commission's System NEISS database, we queried all CFHIs among children from over 100 emergency departments (EDs). Patient information regarding age, race, sex, location of the incident, diagnoses, ED disposition, and sequelae were analyzed. The number of CFHI from all US EDs during each year was also collected from the database. RESULTS: There were an estimated 54,799 (95% CI: 30,228-79,369) total visits to EDs for CFHIs between 2012 and 2021, with a decrease in incidence of approximately 20% during the onset of the COVID-19 pandemic (2019: 5616 cases, 2020: 4459 cases). The annual incidence of injuries showed no significant trend over the 10-year study period. An available subset of 1782 cases of head injuries from approximately 100 EDs was analyzed, and 1442 cases were included in final analysis. Injuries were sorted into three primary categories: unspecified closed head injury (e.g., closed head injury, blunt head trauma, or traumatic brain injury), concussion, or open head injury and skull fracture. Unspecified closed head injuries were the most common of all head injuries (95.4%, 1376/1442). Open head injuries (14/1442, 0.97%) and concussions 3.6% (52/1442, 3.6%) were rare. Most injuries involved children under the age of 1 (42.6%) compared to children who were 1, 2, 3, or 4-years old. About a fourth of patients had other diagnoses in addition to their primary injury including scalp/forehead hematomas, emesis, and contusions. Female patients were more likely to present with other diagnoses in addition to their primary head injury (Difference: 12.3%, 95% CI: 9.87%-15.4%, p < .0001). CONCLUSION: Despite minimum rail height requirements set by the Consumer Safety Product Commission (CPSC), head injuries associated with crib falls are prevalent in the United States. However, most injuries were minor with a vast majority of patients being released following examination and treatment.

Pediatric all-terrain vehicle (ATV) related head injury rates and patterns: A 10-year nationwide analysis.

INTRODUCTION: The use of all-terrain vehicles (ATVs) carries significant risk of permanent injury and death, disproportionately affecting children. These injuries commonly affect the head and are especially severe among children as they are often unhelmeted and more likely than adults to experience rollover injuries. Many studies examining patients with ATV-related injuries are single-center cohort studies, with few focusing specifically on head injuries. In the present study, we aimed to characterize the annual incidence of ATV-related head injuries between 2012 and 2021, classify and compare head injury types, and identify descriptive characteristics of ATV-related head injury victims. METHODS: Using the US Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS) database, we queried all head injuries associated with operating or riding an ATV in children under 18 years-old from over 100 emergency departments (EDs). Patient information regarding age, race, sex, location of incident, diagnoses, and sequelae were analyzed. We also collected the estimated number of ATV-related head injuries from all US EDs using the NEISS algorithm provided by the database. RESULTS: Using the NEISS algorithm we identified 67,957 (95% CI: 43,608 - 92,305) total pediatric ATV-related head injuries between 2012 and 2021. The annual incidence of ATV-related head injury was similar throughout this study period except for a 20% increase during the COVID-19 pandemic period of 2019-2021 (2019: 6382 injuries, 2020: 6757 injuries, 2021: 7600 injuries). A subset of 1890 cases from approximately 100 EDs were then analyzed. Unspecified closed head injuries were the prevailing type of injury (38%, 900/1890), followed by concussions (27%, 510/1890). More severe injuries included intracranial hemorrhages in 91 children (3.8%, 91/1890). Injuries of all types were predominantly seen in 14-17 year-old's (780/1890, 41%) and in males (64.1%, 1211/1890). In addition, ATV-associated injuries were significantly more common in those coded as white (58.0%, 1096/1890) than any other racial group. ATV-associated accidents among children younger than 9 more commonly occurred at the home compared to accidents involving children older than 9 (57% vs. 32%, p < 0.0001). CONCLUSION: ATV-related head injuries cause a significant annual burden among children, with growing incidence in recent years. Further research may wish to explore potential benefits of helmet use and supervision of younger children in possible prevention of these accidents and their associated economic and non-economic costs.

Antibiotic prophylaxis in penetrating traumatic brain injury: analysis of a single-center series and systematic review of the literature.

PURPOSE: Penetrating traumatic brain injury (pTBI) is an acute medical emergency with a high rate of mortality. Patients with survivable injuries face a risk of infection stemming from foreign body transgression into the central nervous system (CNS). There is controversy regarding the utility of antimicrobial prophylaxis in managing such patients, and if so, which antimicrobial agent(s) to use. METHODS: We reviewed patients with pTBI at our institution and performed a PRISMA systematic review to assess the impact of prophylactic antibiotics on reducing risk of CNS infection. RESULTS: We identified 21 local patients and 327 cases in the literature. In our local series, 17 local patients received prophylactic antibiotics; four did not. Overall, five of these patients (24%) developed a CNS infection (four and one case of intraparenchymal brain abscess and meningitis, respectively). All four patients who did not receive prophylactic antibiotics developed an infection (three with CNS infections; one superficial wound infection) compared to two of 17 (12%) patients who did receive prophylactic antibiotics. Of the 327 pTBI cases reported in the literature, 216 (66%) received prophylactic antibiotics. Thirty-eight (17%) patients who received antibiotics developed a CNS infection compared to 21 (19%) who did not receive antibiotics (p = 0.76). CONCLUSIONS: Although our review of the literature did not reveal any benefit, our institutional series suggested that patients with pTBI may benefit from prophylactic antibiotics. We propose a short antibiotic course with a regimen specific to cases with and without the presence of organic debris.

A 20-year nationwide analysis of golf-associated eye injuries in the United States.

PURPOSE: Existing knowledge regarding golf-associated eye injuries (GEIs) is sparse. The purpose of this study was to characterize the types of GEIs, examine the mechanisms of injury, describe the characteristics of GEI victims, and determine the incidence of GEIs during the 2002-2021 period using the National Electronic Injury Surveillance System (NEISS) database. METHODS: Deidentified patient records were analyzed. Each GEI was assigned into a specific category of diagnosis, and the mechanism of injury was determined. National estimates were collected for each year, and simple linear regression modeling was used to determine trends over time. Furthermore, patient variables for sex, race, and age were analyzed. RESULTS: The NEISS query provided a total of 379 GEIs for analysis. GEIs were most common in adult males, with a decreasing, although not statistically significant, trend during this period (ß = -17.88, p = 0.110). Children were more likely to have a GEI caused by a golf club while adults were more likely to have one caused by the surrounding environment. Across all age groups, contusions and corneal abrasions were the most common GEIs, constituting 50.4% (190/377) of all eye injuries, followed by foreign body injuries (9%, 34/377) and then irritation/inflammation of the eye (8%, 30/377). The most common mechanism of injury among all players involved adverse interactions with the environment (37.7%, 142/377). CONCLUSION: Contradictory to existing literature, we show that minor GEIs are more common than severe ones. Rather than golf clubs or balls, environmental elements are the leading cause of GEIs.

Cranial Irradiation for Childhood Cancers and Adult Risk of Meningioma.

INTRODUCTION: Following cranial irradiation, there is an increased risk of developing secondary neoplasms, especially meningiomas. Despite childhood cancer survivors who have undergone cranial irradiation having an increased risk of acquiring radiation-induced meningioma (RIM), there is no widely used standard guideline for meningioma screening. METHODS: At a single institution, we reviewed three adult survivors of childhood cancer who were treated for RIM between 2010 and 2020. We recorded age at diagnosis for the primary lesion, the radiation dose, age at RIM diagnosis, and tumor characteristics including treatment, pathology, and outcome. Two had had T-cell acute lymphocytic leukemia and one a rhabdomyosarcoma. The age of diagnosis of the RIM ranged from 20 to 40 years, with latencies ranging from 18 to 33 years. All lesions were classified as WHO Grade I meningiomas, and only 1 patient had a subsequent recurrence. A literature search identified articles that address RIM: a total of 684 cases were identified in 36 publications. RESULTS: Mean radiation doses ranged from 1.4 gray to 70 gray. Mean age of diagnosis for secondary meningioma ranged from 8 to 53.4 years old, with latency periods ranging from 2.8 to 44 years. Given variability in the way that investigators have published their results, it is difficult to make a single recommendation for RIM screening. Using our experience and the literature, we devised two different screening protocols and calculated their expense. CONCLUSIONS: We recommend that data be standardized in a registry to provide greater insight into the clinical and resource allocation questions, especially as long-term survival of children with pediatric cancer into full adulthood becomes more commonplace worldwide.

Disparities in Primary Spinal Osseous Malignant Bone Tumor Survival by Medicaid Status: A National Population-Based Risk Analysis.

BACKGROUND: The impact of Medicaid status on survival outcomes of patients with spinal primary malignant bone tumors (sPMBT) has not been investigated. METHODS: Using the SEER-Medicaid database, adults diagnosed between 2006 and 2013 with sPMBT including chordoma, osteosarcoma, chondrosarcoma, Ewing sarcoma, or malignant giant cell tumor (GCT) were studied. Five-year survival analysis was performed using the Kaplan-Meier method. Adjusted survival analysis was performed using Cox proportional-hazards regression controlling for age, sex, marital status, cancer stage, poverty level, vertebral versus sacral location, geography, rurality, tumor diameter, tumor grade, tumor histology, and therapy. RESULTS: A total of 572 patients with sPMBT (Medicaid: 59, non-Medicaid: 513) were identified. Medicaid patients were more likely to be younger (P < 0.001), Black (P < 0.001), live in high poverty neighborhoods (P = 0.006), have distant metastases at diagnosis (P < 0.001), and less likely to receive surgery (P = 0.006). The 5-year survival rate was 65.7% (chondrosarcoma: 70.0%, chordoma: 91.5%, Ewing sarcoma: 44.6%, GCT: 90.0%, osteosarcoma: 34.2%). Medicaid patients had significantly worse 5-year survival than non-Medicaid patients (52.0% vs. 67.2%, P = 0.02). Minority individuals on Medicaid were associated with an increased risk of cancer-specific mortality compared with White non-Medicaid patients (adjusted hazard ratio [aHR] = 2.51, [95% CI 1.18-5.35], P = 0.017). Among Medicaid patients, those who received surgery had significantly better survival than those who did not (64.5% vs. 30.6%, P = 0.001). For all patients, not receiving surgery (aHR = 1.90 [1.23-2.95], P = 0.004) and tumor diameter >50 mm (aHR=1.89 [1.10-3.25], P = 0.023) were associated with an increased risk of mortality. CONCLUSIONS: Medicaid patients may be less likely to receive surgery and suffer from poorer survival. These disparities may be especially prominent among minorities.

Social determinants of health and outcome disparities in spine tumor surgery. Part 2: Neighborhood disadvantage and long-term outcomes.

OBJECTIVE: Neighborhood-level resource disadvantage has been previously shown to predict extent of resection, oncological follow-up, adjuvant treatment, and clinical trial participation for malignancies, including glioblastoma. The authors aimed to characterize the association between neighborhood disadvantage and long-term outcomes after spine tumor surgery. METHODS: The authors analyzed all patients who underwent surgery for primary or secondary (all metastatic pathologies) spine tumors at a single spinal oncology specialty center in the United States from 2015 to 2022. The Area Deprivation Index (ADI), a validated metric compositing 17 social determinants of health variables that ranges continuously from 0% (higher advantage) to 100% (higher disadvantage), was used to quantify neighborhood disadvantage. Patient addresses were matched to ADI on the basis of the census block of residence. Subsequently, the study population was dichotomized into advantaged (ADI 0%-33%) and disadvantaged (ADI 34%-100%) cohorts. The primary endpoint was functional status, as defined by Eastern Cooperative Oncology Group (ECOG) Performance Status Scale grade, with secondary endpoints including inpatient outcomes, mortality, readmissions, reoperations, and clinical research participation. Multivariable logistic, gamma log-link, and Cox regression adjusted for 14 confounders, including patient and oncological characteristics, general and tumor-related presenting severity, and treatment. RESULTS: In total, 237 patients underwent spine tumor surgery from 2015 to 2022, with an average age of 53.9 years, and 57.0% had primary tumors whereas 43.0% had secondary tumors; 55.3% (n = 131) were classified by ADI into the disadvantaged cohort. This cohort had higher rates of ambulation deficits on presentation (39.1% vs 23.5%, p = 0.015) and nonelective surgery (35.1% vs 23.6%, p = 0.030). Postoperatively, disadvantaged patients exhibited higher odds of residual tumor (OR 2.55, p = 0.026), especially for secondary tumors (OR 4.92, p = 0.045). Patients from disadvantaged neighborhoods additionally exhibited significantly higher odds of poor functional status at follow-up (OR 3.94, p = 0.002). Postoperative survival was 74.7% (mean follow-up 17.6 months), with the disadvantaged cohort experiencing significantly shorter survival (HR 1.92, p = 0.049). Moreover, this population had higher odds of readmission (OR 1.92, p = 0.046) and, for primary tumors, reoperation (OR 9.26, p = 0.005). Elective participation in prospective clinical research was lower among the disadvantaged cohort (OR 0.45, p = 0.016). CONCLUSIONS: Neighborhood disadvantage predicts higher rates of residual tumor, readmission, and reoperation, as well as poorer functional status, shorter postoperative survival, and decreased elective research participation. The ADI may be used to risk stratify spine oncology patients and guide targeted interventions to ameliorate neurosurgical disparities and to reduce barriers to research participation.

Social determinants of health and outcome disparities in spine tumor surgery. Part 1: An analysis of 6.6 million nationwide admissions.

OBJECTIVE: Earlier research has demonstrated that social determinants of health (SDoH) impact neurosurgical access and outcomes, but these trends are less characterized for spine tumors relative to intracranial tumors. The authors aimed to elucidate the association between SDoH and outcomes for a nationwide cohort of spine tumor surgery admissions. METHODS: The authors identified all admissions with a spine tumor diagnosis in the National Inpatient Sample (NIS) from 2002 to 2019. Four SDoH were analyzed: race and ethnicity, insurance, household income, and safety-net hospital (SNH) treatment. Hospitals in the top quartile of safety-net burden (in terms of percentage of patients receiving Medicaid or uninsured) were categorized as SNHs. Multivariable regression queried the association between 22 variables and 5 perioperative outcomes: mortality, discharge disposition, complications, length of stay (LOS), and hospitalization costs. Interaction term analysis with hospitalization year was used to assess longitudinal changes in outcome disparities. Finally, the authors constructed random forest machine learning models to assess the impact of SDoH variables on prognostic accuracy and to quantify the relative importance of predictors for disposition. RESULTS: Of 6,593,392 total admissions with spine tumors, 219,380 (3.3%) underwent surgery. Non-White race (OR 0.80-0.91, p < 0.001) and nonprivate insurance (OR 0.76-0.83, p < 0.001) were associated with lower odds of receiving surgery. Among surgical admissions, presenting severity, including of myelopathy and plegia, was elevated among non-White, nonprivate insurance, and low-income admissions (all p < 0.001). Black race (OR 0.70, p < 0.001), Medicare (OR 0.70, p < 0.001), Medicaid (OR 0.90, p < 0.001), and lower income (OR 0.88-0.93, all p < 0.001) were associated with decreased odds of favorable discharge disposition. Increased LOS and costs were observed among non-White (+6%-10% in LOS and +5%-9% in costs, both p < 0.001) and Medicaid (+16% in LOS and +6% in costs, both p < 0.001) admissions. SNH treatment was also associated with higher mortality (OR 1.49, p < 0.001) and complication (OR 1.20, p < 0.001) rates. From 2002 to 2019, disposition improved annually for Medicaid patients (OR 1.03 per year, p = 0.022) but worsened for Black patients (OR 0.98 per year, p = 0.046). Random forest models identified household income as the most important predictor of discharge disposition. CONCLUSIONS: For spine tumor admissions, SDoH predicted surgical intervention, presenting severity, and perioperative outcomes. Over 2 decades, disparities improved for Medicaid patients but worsened for Black patients. Finally, SDoH significantly improve prognostic accuracy for outcomes after spine tumor surgery. Further study toward ameliorating patient disparities for this population is warranted.