Early Celecoxib Use in Spontaneous Intracerebral Hemorrhage is Associated with Reduced Mortality.

BACKGROUND: Hemorrhagic strokes constitute 10-15% of all strokes and have the worst mortality and morbidity of all subtypes. Mortality and morbidity of spontaneous intracerebral hemorrhage (sICH) are often secondary to the effects of inflammation, brain edema, and swelling. Studies have shown that celecoxib, a selective cyclooxygenase 2 (COX-2) inhibitor, reduces perihematomal edema formation and inflammation. This study aimed to examine the impact of celecoxib on sICH outcomes. METHODS: TriNetX, a multi-institutional research database, was retrospectively queried to identify patients with sICH. Outcomes in patients who received celecoxib within 5 days (cohort 1) were analyzed and compared to those in patients who did not receive celecoxib (cohort 2). The primary end point was mortality within 1 year of sICH. Secondary end points included ventilator dependence, tracheostomy, percutaneous endoscopic gastrostomy tube placement, craniotomy, deep venous thrombosis, pulmonary embolism, ischemic stroke, transient ischemia attack, myocardial infarction, and seizures. Further analysis was performed to assess these outcomes for patients treated with ibuprofen, a nonselective COX inhibitor. RESULTS: After propensity score matching, 833 patients were identified in each cohort based on celecoxib use. Mortality at 1 year was significantly reduced in patients with sICH receiving celecoxib compared to those who did not (13.33% vs. 17.77%; p = 0.0124). Risks of ventilator dependence, tracheostomy, percutaneous endoscopic gastrostomy tube placement, craniotomy, deep venous thrombosis, pulmonary embolism, ischemic stroke, transient ischemia attack, myocardial infarction, and seizures were not significantly increased in patients who received celecoxib within 5 days of sICH compared to those who did not receive celecoxib. There was no significant difference in mortality between patients based on ibuprofen administration. CONCLUSIONS: There exists a growing interest in using COX-2 as a potential target strategy for neuroprotection in patients with sICH, with some evidence of a mortality benefit in small cohort studies. This study shows that early celecoxib use is associated with decreased mortality in patients with sICH.

Pregnancy in spina bifida patients: a comparative analysis of peripartum procedures and complications.

PURPOSE: Spina bifida (SB) is caused by a failure in neural tube closure that can present with lower extremity sensory deficits, paralysis, and hydrocephalus. Medical advances have allowed increased pregnancies among SB patients, but management and pregnancy-associated complications have not been thoroughly investigated. The objective is to delineate peripartum procedures and complications in patients with SB. METHODS: A national de-identified database, TriNetX, was retrospectively queried to evaluate pregnant SB patients and the general population. Procedures and complications were investigated using corresponding ICD-10 and CPT codes within 1 year of pregnancy diagnosis. RESULTS: 11,405 SB patients were identified and compared to 9,269,084 non-SB patients. SB patients were significantly more likely to undergo cesarean delivery (1.200; 95% CI [1.133-1.271]) and less likely to receive neuraxial analgesia (0.406; 95% CI [0.383-0.431]). Additionally, patients with SB had an increased risk of seizures (3.922; 95% CI [3.529-4.360]) and venous thromboembolism (VTE) (3.490; 95% CI [3.070-3.969]). Risks of preeclampsia and hemorrhage were comparable. SB patients with hydrocephalus and Chiari malformation type 1 (CM-1) or type 2 (CM-2) were compared to patients without these comorbid conditions. This sub-group analysis showed a significantly increased risk of having cesarean deliveries (SB with hydrocephalus: 12.55%, S.B. with CM-1 or CM-2: 12.81% vs. SB without hydrocephalus or CM, 6.16%) and VTE (3.74%, 2.43% vs. 0.81%). There were also increased risks of hemorrhage and seizures and decreased use of neuraxial analgesia, but the sample size was insufficient. CONCLUSION: SB patients were more likely to undergo cesarean section and exhibit peripartum complications compared to those without SB.

Early Celecoxib use in Patients with Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) can cause rapid brain inflammation. There is debate over the safety and efficacy of anti-inflammatory agents in its treatment. With a particular focus on cyclooxygenase 2 (COX2) selective inhibition, we sought to determine the impact of celecoxib versus no celecoxib treatment on outcomes in patients with TBI and compare these with outcomes associated with nonselective COX inhibition (ibuprofen) and corticosteroid (dexamethasone) treatment. METHODS: This retrospective cohort study used TriNetX, a large publicly available global health research network, to gather clinical data extracted from the electronic medical records. Using International Classification of Diseases, Tenth Revision and pharmacy codes, we identified patients with TBI who were and were not treated with celecoxib, ibuprofen, and dexamethasone. Analysis was performed on propensity-matched and unmatched cohorts, which were matched on demographics, comorbidities, and neurological injuries. Our primary end point was 1-year survival. Secondary end points were ventilator and tracheostomy dependence, gastrostomy tube placement, seizures, and craniotomy. RESULTS: After propensity score matching, a total of 1443 patients were identified in both the celecoxib and no celecoxib cohorts. Ninety-two (6.4%) patients in the celecoxib cohort died within 1 year following TBI versus 145 (10.0%) in the no celecoxib cohort (odds ratio 0.61; 95% confidence interval 0.46-0.80; p = 0.0003). The 1-year survival rate was 96.1% in the celecoxib cohort versus 93.1% in the no celecoxib cohort (p < 0.0001). At the end of the 1-year period, celecoxib was associated with significantly lower gastrostomy tube dependence (p = 0.017), seizure activity (p = 0.027), and myocardial infarction (p = 0.021) compared with the control cohort. Ibuprofen was also associated with higher 1-year survival probability and lower rates of post-TBI complications. Dexamethasone was broadly associated with higher morbidity but was associated with higher 1-year survival probability compared with the no dexamethasone cohort. CONCLUSIONS: Early celecoxib and ibuprofen use within 5 days post TBI was associated with higher 1-year survival probabilities and fewer complications. With emerging yet controversial preclinical evidence to suggest that COX inhibition improves TBI outcomes, this population-level study offers suggestive support for these drugs' clinical benefit, which should be pursued in prospective clinical studies.

Outcomes of pregnancy and childbirth in women with hidradenitis suppurativa.

BACKGROUND: Many women affected by hidradenitis suppurativa (HS) are of childbearing age. To date, the literature is limited on pregnancy-related outcomes for women with HS. OBJECTIVE: To investigate maternal and obstetric outcomes and treatment utilization among women with HS. METHODS: This retrospective analysis used the IBM MarketScan Commercial Claims Database. Pregnant women with HS (n = 998) and 5:1 age-matched pregnant women without HS (n = 5065) were identified and information on claims related to diagnoses, procedures, and medications were analyzed. RESULTS: Compared to women without HS, pregnant women with HS had significantly lower odds of having a live birth (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.39-0.51) and significantly higher odds of having elective terminations (OR, 2.51; 95% CI, 2.13-2.96), gestational hypertension (OR, 1.44; 95% CI, 1.12-1.84), and cesarean deliveries (OR, 1.28; 95% CI, 1.06-1.55), and of receiving HS designated treatment during pregnancy (OR, 4.41; 95% CI, 3.56-5.46). LIMITATIONS: Retrospective and convenience sampling and absence of clinical information to correlate HS severity and outcomes. CONCLUSION: Pregnant women with HS have an increased probability of select complicated maternal and obstetric outcomes. Women planning for pregnancy or who are currently pregnant may benefit from coordinated care by dermatologists and obstetric providers.

Drunken Membranes: Short-Chain Alcohols Alter Fusion of Liposomes to Planar Lipid Bilayers.

Although the effects of ethanol on protein receptors and lipid membranes have been studied extensively, ethanol's effect on vesicles fusing to lipid bilayers is not known. To determine the effect of alcohols on fusion rates, we utilized the nystatin/ergosterol fusion assay to measure fusion of liposomes to a planar lipid bilayer (BLM). The addition of ethanol excited fusion when applied on the cis (vesicle) side, and inhibited fusion on the trans side. Other short-chain alcohols followed a similar pattern. In general, the inhibitory effect of alcohols (trans) occurs at lower doses than the excitatory (cis) effect, with a decrease of 29% in fusion rates at the legal driving limit of 0.08% (w/v) ethanol (IC50 = 0.2% v/v, 34 mM). Similar inhibitory effects were observed with methanol, propanol, and butanol, with ethanol being the most potent. Significant variability was observed with different alcohols when applied to the cis side. Ethanol and propanol enhanced fusion, butanol also enhanced fusion but was less potent, and low doses of methanol mildly inhibited fusion. The inhibition by trans addition of alcohols implies that they alter the planar membrane structure and thereby increase the activation energy required for fusion, likely through an increase in membrane fluidity. The cis data are likely a combination of the above effect and a proportionally greater lowering of the vesicle lysis tension and hydration repulsive pressure that combine to enhance fusion. Alternate hypotheses are also discussed. The inhibitory effect of ethanol on liposome-membrane fusion is large enough to provide a possible biophysical explanation of compromised neuronal behavior.

Effects of Preoperative Glucocorticoid Use on Patients Undergoing Single-Level Lumbar Fusions: A Retrospective Propensity Score-Matched Registry Study.

Objective Spinal fusions are gaining popularity as a means of treating spinal deformity and instability from a range of pathologies. The prevalence of glucocorticoid use has also increased in recent decades, and their systemic effects are well-documented. Although commonly used in the preoperative period, the effects of steroids on outcomes among patients undergoing spinal fusions are inadequately described. This study compares the odds of developing complications among patients who underwent single-level lumbar fusions with and without preoperative glucocorticoid use in hopes of establishing more evidence-based parameters for guiding preoperative steroid use. Methods The TriNetX multi-institutional electronic health record database was used to perform a retrospective, propensity score-matched analysis of clinical outcomes of two cohorts of patients who underwent posterior or posterolateral single-level lumbar fusions with and without interbody fusion, those who used glucocorticoids for at least one week within a year of fusion and those who did not. The outcomes of interest were examined within 30 days of the operation and included death, reoperation, deep or superficial surgical site infection (SSI), pneumonia, reintubation, ventilator dependence, tracheostomy, acute kidney injury (AKI), renal insufficiency, pulmonary embolism (PE) or deep venous thrombosis (DVT), urinary tract infection (UTI), emergency department (ED) visit, sepsis, and myocardial infarction (MI). Results The odds of developing pneumonia within 30 days of spinal fusion in the cohort that used glucocorticoids within one year of operation compared to the cohort without glucocorticoid use was 0.67 (p≤0.001, 95% CI: 0.59-0.69). The odds of requiring a tracheostomy within 30 days of spinal fusion in the cohort that used glucocorticoids within one year of operation compared to the cohort without glucocorticoid use was 0.39 (p≤0.001, 95% CI: 0.26-0.60). The odds of reoperation, deep and superficial SSI, and ED visits within 30 days of operation were significantly higher for the same glucocorticoid-receiving cohort, with odds ratios of 1.4 (p=0.003, 95% CI: 1.11-1.65), 1.86 (p≤0.001, 95% CI: 1.31-2.63), 2.28 (p≤0.001, 95% CI: 1.57-3.31), and 1.25 (p≤0.001, 95% CI: 1.17-1.33), respectively. After propensity score-matching, there was no significant difference between the odds of death, DVT, PE, MI, UTI, AKI, sepsis, reintubation, and ventilator dependence between the two cohorts. Conclusion In support of much of the current literature regarding preoperative glucocorticoid use and rates of complications, patients who underwent a single-level lumbar fusion and have used glucocorticoids for at least a week within a year of operation experienced significantly higher odds of reoperation, deep and superficial SSI, and ED visits. However, these patients using glucocorticoids were also found to have lower odds of developing pneumonia, renal insufficiency, and tracheostomy requirement than those who did not use steroids within a year of surgery.

Lumbar Puncture in Thrombocytopenia: The Floor Is Not Firm.

Objective Lumbar puncture (LP) is a diagnostic procedure that accesses the spinal subarachnoid space to measure the opening pressure of the cerebrospinal fluid (CSF) and obtain samples of CSF for analysis. Although commonly performed, LPs are associated with the risk of morbidity and mortality. In addition, thrombocytopenia is thought to increase the risk of LP complications, particularly spinal bleeds. This study compares rates of complications among patients who received LPs with and without thrombocytopenia in hopes of establishing more evidence-based platelet thresholds for an LP. Methods The TriNetX multi-institutional electronic health record database was used to perform a retrospective propensity score-matched analysis of clinical outcomes of two cohorts of patients who underwent LPs - those with thrombocytopenia (defined as a platelet level of 10,000-50,000 platelets {plts}/µL) and those without thrombocytopenia. The outcomes of interest were the new occurrence of subdural hematoma, epidural hematoma, subarachnoid hemorrhage, receipt of a blood patch, new onset of paralysis, and requirement of spinal decompression. Results The risk of developing a spinal bleed following an LP was 1.496% (42 of 2,808) for the cohort with thrombocytopenia versus 1.09% (31 of 2,843) for the cohort without thrombocytopenia. The risk difference, risk ratio, and odds ratio of patients from these two cohorts experiencing a spinal bleed following an LP were insignificant at 0.05. The risk of receiving a blood patch following an LP was 7.844% for those with thrombocytopenia compared to 1.421% for those without thrombocytopenia. The odds ratio of receiving a blood patch between the two cohorts was 5.906, significant to the 0.05 level (95% CI: 4.213-8.279). There was no significant difference in the cohorts' risk of developing paralysis or requiring spinal decompression following an LP. Conclusion In support of recent findings against conventional platelet count thresholds prior to LP, it was observed in the present study that the incidence of post-LP spinal bleeding in the 30 days after LP is not associated with platelet counts below the guideline threshold of 50,000 plts/µL. Patients with thrombocytopenia are also not significantly more likely to require spinal decompression or develop new onset paralysis. However, thrombocytopenia is associated with a significantly increased likelihood of receiving a blood patch following an LP.

Mental health and substance use disorders in young adults with spina bifida.

OBJECTIVE: Although medical advances have allowed most patients with spina bifida (SB) to survive into adulthood, these patients may have physical impairments, urological complications, infections, and neurocognitive deficits. These factors can cause psychological distress and impact the transition from pediatric to adult care. There remains limited research on mental health disorders (MHDs) and substance use disorders (SUDs) in SB patients during this vulnerable transition period. This study aimed to investigate the 10-year incidence of MHDs and SUDs in 18- to 25-year-old patients with SB. METHODS: TriNetX, a federated de-identified database, was retrospectively queried to identify 18- to 25-year-old patients with SB. The presence of MHDs and SUDs based on ICD-10 codes in SB patients (cohort 1) was analyzed and compared with those of patients without SB (cohort 2). Subgroup analysis was performed on SB patients with hydrocephalus and neurogenic bladder (NB). SB patients were further compared to patients with a spinal cord injury (SCI). RESULTS: After propensity score matching, the authors identified 1494 patients in each cohort. SB patients were more likely to have depression (OR 1.949, 95% CI 1.64-2.317), anxiety (OR 1.603, 95% CI 1.359-1.891), somatoform disorders (OR 2.102, 95% CI 1.052-4.199), and suicidal ideations or attempts and self-harm (OR 1.424, 95% CI 1.014-1.999). The prevalence of attention-deficit/hyperactivity disorder (ADHD) and eating disorders were comparable between cohorts. SB patients also had increased rates of nicotine dependence (OR 1.546, 95% CI 1.22-1.959) but not of alcohol or opioid disorders. In SB patients, the presence of hydrocephalus and NB was not associated with significantly increased rates of any measured MHDs or SUDs. When compared with SCI patients, SB patients were more likely to have anxiety (OR 1.377, 95% CI 1.028-1.845) and ADHD (OR 1.875, 95% CI 1.084-3.242). However, SB patients had lower rates of nicotine dependence (OR 0.682, 95% CI 0.482-0.963) and opioid-related disorders (OR 0.434, 95% CI 0.223-0.845). SB and SCI patients shared similar rates of depression, suicidal ideations or attempts and self-harm, and alcohol-related disorders. CONCLUSIONS: Young adults with SB have higher prevalence rates of MHDs and SUDs compared with the general population. Therefore, incorporation of mental health and substance use management is critical to facilitate transition to adulthood.

Epidural Steroid Injection Prior to Spinal Surgery: A Step-Wise and Wise Approach.

BACKGROUND: An epidural steroid injection (ESI) is used to treat a number of morbid central nervous system pathologies and is considered a reasonably safe procedure. This study aimed to determine the relative infection risk after spinal surgery by comparing outcomes in spinal surgery patients who received an ESI shortly prior to the surgery against those who did not receive an ESI shortly prior to the surgery. METHODS: The present study is a retrospective cohort study using a multi-institutional healthcare database, TriNetX, to collect data on patients who received spinal surgery with and without having had ESIs six months before surgery. Two cohorts were generated: Cohort 1 included patients who had received an ESI in the six months prior to spinal surgery, and cohort 2 included patients who did not have an ESI in the six months prior to spinal surgery. The patients in cohort 2 had propensity scores matched 1:1 to those in cohort 1 using common baseline demographics, comorbidities and spinal procedure indications. The spinal procedures and surgeries considered for the analysis included open procedures for any purpose, including exploration, decompression, resection, revision or biopsy. Multiple outcomes were compared across these two cohorts in the three months following the spinal procedure/surgery, including the occurrence of death, surgical site infection, epidural and/or spinal abscess, and dural tear. RESULTS: An ESI in the six months prior to spinal surgery was associated with a significant decrease in the likelihood epidural/spinal abscess in the three months after surgery. There was no change in mortality, wound infection or identification of dural tear in the three months after spinal surgery for those who received an ESI six months before spinal surgery. CONCLUSION: This data suggests that epidural steroid injections' anti-inflammatory effects provide benefits before surgery beyond symptomatic relief. Given that the degeneration of spinal pathologies is typically advanced rather than corrected by the body's inflammatory response, it is likely that preventing hyperactivation of the body's immune system in the months preceding surgical intervention, a traumatic insult, is protective compared to no intervention and, importantly, without major adverse effects.

Telemedicine in a spine clinic setting: a large survey of patient preferences and experiences.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has greatly disturbed healthcare and the practice of neurosurgery. As healthcare systems evolve in the face of COVID-19, the use of telehealth platforms has expanded. We presented the results of a large survey of patient perspectives on the role of telehealth in the care of spine clinic patients. METHODS: All patients at the spine clinic of a large, tertiary, academic medical center were surveyed at their clinic visit from May 30, 2020-June 30, 2020. All responses were anonymous, and results were analyzed with standard statistical techniques. RESULTS: One hundred and seventy-six surveys were returned and 164 were entirely completed. 56.8% of patients were new while 24.4% were postoperative follow-up visits: 54.9% had lumbar symptoms. 85% had pain while more than half also reported weakness; 58% traveled greater than twenty-five miles for their appointment; 96% had transportation readily available. Of all respondents, only 15.3% preferred the appointment via video telehealth while 4% had no preference between in-person appointment or virtual visit. Preference for telehealth appointment was not associated with factors such as new or established in the practice, spinal region of symptoms, pain, weakness, comfort with technology, age, or duration of symptoms. There was a significant difference between how far the patient traveled for the clinic appointment and their preference for a telehealth appointment, with patients traveling further distances favoring telehealth (P=0.04). This effect remained significant when stratifying based on 25 miles (P=0.03) or 50 miles (P=0.03) but not when stratifying based on 100 miles (P=0.32). However, the sample size of patients traveling >100 miles was small, limiting any inference regarding that subgroup. Access to transportation was associated with preference for telehealth (88.89% vs. 97.18%, P=0.08) but did not reach statistical significance. CONCLUSIONS: Most spine patients prefer in-person clinic appointments to virtual appointments. These preferences should be considered when arranging patient encounters.

Blood Pressure Control in Traumatic Subdural Hematomas.

Background There is debate over optimal systolic blood pressure (SBP) after traumatic subdural hematoma. Increased SBP has the benefit of increasing cerebral perfusion pressure and limiting the detrimental secondary effects of traumatic brain injury but poses a risk of hematoma expansion. While prior studies have shown that SBP<90mmHg is associated with worsened morbidity and mortality in subdural hematoma patients, clinical guidelines and expert opinion have differing initial SBP goals. The aim of this study is to leverage a large database to determine the effects of two such goals, namely SBP 100-150mmHg versus SBP<180mmHg in this patient population. Methods A de-identified database network (TriNetX Research Network) was used to retrospectively query all patients with a first instance diagnosis of acute traumatic SDH, who also had a recorded GCS, with maintenance of SBP 100-150 within the first 24 hours (cohort 1) versus patients with an SBP<180 (cohort 2). Data came from 68 health care organizations (HCOs) with a total of 105,897,964 patients on 9/1/2022. The primary outcome of interest was mortality within 30 days. Secondary outcomes include gastrostomy tube placement, craniotomy/craniectomy/burr hole drainage, venous thromboembolism, ischemic stroke, myocardial infarction, seizure, falls, cardiac arrest, and acute kidney injury within 30 days. Cohorts were propensity-score matched for confounders. Results After propensity score matching, 1,243 patients were identified in each cohort. Age at index was 57.97+/-23.21 years and 58.28+/-22.35 years for cohorts 1 and 2, respectively. Mortality was seen in 243 patients (19.756%) vs. 209 (16.992%) (OR 1.203, 95% CI (0.98,1.476), p=0.0767) in cohorts 1 and 2, respectively. There was no statistical difference in secondary outcomes. Conclusion The results of this study demonstrate that the primary outcome of mortality at 30 days is not statistically different in acute traumatic SDH patients, whether their SBP is kept at 100-150 or below 180. Likewise, it shows no statistical difference in the subsequent incidence of gastrostomy tube placement, craniotomy/craniectomy/burr holes, venous thromboembolism, ischemic stroke, myocardial infarction, seizure, falls, or acute kidney injury.

Ventriculoperitoneal Shunt and Gastrostomy Tube Placement and Timing: A Database Analysis.

Background Debate exists about the safety of ventriculoperitoneal shunt placement in the presence of a gastrostomy tube and the timing of these procedures from each other. Using a large database, we sought to determine the rates of shunt infection and revision in patients who had both devices placed, based on the timing between procedures. Methods We performed a retrospective database analysis using a multi-institutional database (TriNetX), looking at all patients diagnosed with gastrostomy tube with subsequent ventriculoperitoneal shunt placement and vice-versa. We also evaluated patients who had gastrostomy tubes and shunts placed at the same time. We categorized cohorts into patients with device placement after 1-10 days, 11-30 days, and after one month of the other. Our primary endpoints were shunt infection and shunt revision. Results Patients who had same-day gastrostomy tube and shunt placement had a shunt infection rate of 10.06% within five years, and 14.53% had a shunt revision. With prior shunting and subsequent gastrostomy tube placement within 1-10 days, 12.18% had shunt infections, and 17.88% had shunt revisions; for those who had subsequent gastrostomy tube placement within 11-30 days, shunt infections were seen in 10.57%, and shunt revisions in 19.41%; gastrostomy tube placement after one month or longer of shunt placement resulted in 15.39% of patients having shunt infections and 17.73% with shunt revision. Prior gastrostomy tube patients with subsequent shunt placement, within 1-10 days had shunt infection rates of 8.27% and revision rates of 14.39%; for shunt placement within 11-30 days, shunt infections were seen in 10.82%, and shunt revisions were done in 14.33% of patients; for shunt placement after one month or longer, shunt infection rate was 11.68%, and revision rate was 16.80%. Conclusions Our results demonstrate no significant difference in shunt infection rates and shunt revision rates between same-day gastrostomy tube and shunt placement versus placement within 1-10 days, 11-30 days, or any time after one month from one another.

COVID-19 and Ventricular Shunt Revisions.

INTRODUCTION: COVID-19 patients frequently experience headaches, malaise, and fatigue. For patients with shunted hydrocephalus, these signs and symptoms can often be indicative of shunt failure. Thus, it can be challenging to determine if shunt failure has occurred in this patient population. Therefore, we explored the question of how a diagnosis of COVID-19 in shunted hydrocephalus patients influences the rate of shunt revision. METHODS: We used a deidentified database network (TriNetX) to gather information on patients with shunted hydrocephalus and COVID-19 versus no COVID-19 from January 20, 2020, through September 26, 2021. Our primary outcome of interest was shunt revision at 90 days, with secondary outcomes of mortality, hospitalization, ICU admission, mechanical ventilation, tracheostomy, PEG tube placement, fall, seizure, acute kidney injury (AKI), venous thromboembolism (VTE), ischemic stroke (I.S.), myocardial infarction (MI), and sepsis. Cohorts were propensity score-matched for common comorbidities and demographics. RESULTS: After propensity score matching, 10,600 patients with shunted hydrocephalus and COVID-19 (cohort 1) and 10,600 patients with shunted hydrocephalus and no COVID-19 (cohort 2) were identified. Average age was 38.5 years. Eight hundred and thirty-four patients (7.869%) in cohort 1 and 180 (1.698%) patients in cohort 2 underwent shunt revision (p=<0.0001, OR 4.978, 95% CI 4.198, 5.821). Mortality was 4.642% vs. 2.113% (p<0.0001, OR 2.255, 95% CI 1.921, 2.647). Hospitalization rates were 27.72% vs. 10.303% (p<0.0001), and ICU admission rates 11.567% vs. 3.463% (p<0.0001). Ventilator dependence was 3.529% vs. 0.953% (p<0.0001), tracheostomy 1.142% vs. 0.236% (p<0.0001), PEG tube insertion 2.472% vs. 0.585% (p<0.0001), falls 2.321% vs. 1.076% (p<0.0001), seizure 11.369% vs. 5.953% (p<0.0001), AKI 4.416% vs. 1.717% (p<0.0001), VTE 3.538% vs. 1.293% (p<0.0001), sepsis 3.887% vs. 1.179% (p<0.0001), IS 0.585% vs. 0.16% (p<0.0001), and MI 1.34% vs. 0.519% (p<0.0001). CONCLUSION: COVID-19 infection is associated with an almost five-fold increase in shunt revisions.

A Retrospective Comparative Cohort Study of Craniotomy and Prophylactic Enoxaparin Timing.

INTRODUCTION:  Post-operative venous thromboembolism (VTE) prophylaxis is the standard of care after craniotomy, but there is debate over when to initiate VTE prophylaxis to decrease the morbidity and mortality experienced by these patients. This study aims to determine the effects of starting enoxaparin on day one vs. day three after craniotomy. METHODS: We used a multi-institutional health research network (TriNetX) to gather data from the electronic medical records of patients who started enoxaparin one day after craniotomy (cohort 1) and patients who started it three days later (cohort 2). Our primary endpoint was mortality, with the secondary endpoints of deep venous thrombosis (DVT), additional craniotomy, pulmonary embolism (PE), myocardial infarction (MI), ischemic stroke (IS), intracerebral hemorrhage (ICH), ventilator and tracheostomy dependence, or percutaneous endoscopic gastrostomy (PEG) tube dependence. Patients were propensity score-matched for demographics, common comorbidities, and anticoagulant and antiplatelet use. RESULTS: After propensity score matching, 1,554 patients were identified in each cohort. In cohort 1, 21.171% of patients were deceased after five years vs. 26.126% in cohort 2 (p= 0.0012; OR 0.759, 95% CI (0.643,0.897)). The 30-day survival was 94.521% vs. 93.049%, the 90-day survival was 90.200% vs. 87.335%, and the 365-day survival was 80.619 vs. 76.817%. Deep venous thrombosis occurred in 5.277% of cohort 1 and 7.851% of cohort 2 (p=0.0038, OR 0.654, 95% CI [0.49,0.873]). There was no increase in intracerebral hemorrhage in cohort 1. There were no statistically significant differences in subsequent craniotomy rates, PE, MI, IS, ventilator/tracheostomy, or PEG tube dependence. CONCLUSION: Starting enoxaparin on day one after craniotomy was associated with decreased mortality and DVTs, with no difference in rates of PE, MI, IS, tracheostomy/PEG dependence, or further craniotomy.

Obesity Paradox and Surgical Evacuation for Chronic Subdural Hematoma.

BACKGROUND:  Chronic subdural hematoma (cSDH) has a number of risk factors for recurrence, and some studies suggest obesity is one of them. Yet obesity has been shown to have a positive survival benefit in many diseases such as ischemic stroke, chronic obstructive pulmonary disease, percutaneous coronary intervention, and mechanical thrombectomy. Therefore, we sought to determine if obesity provided a mortality benefit in patients with cSDH undergoing burr hole drainage or craniotomy. METHODS:  We performed a retrospective database analysis using a multi-institutional (TriNetX) database looking at obese versus non-obese patients with cSDH undergoing surgical drainage. Our primary endpoint was mortality. Secondary endpoints included seizure, pulmonary embolism (PE), myocardial infarction (MI), cerebral infarction, deep vein thrombosis (DVT), tracheostomy, and percutaneous endoscopic gastrostomy (PEG). These were looked at to obtain a better idea of prognosis. Cohorts were propensity score-matched for confounders, using the greedy-nearest neighbor algorithm with a caliper of 0.1 pooled standard deviations. Kaplan-Meier survival curves were also developed, and hazard ratios were calculated. Chi-square analysis was performed on categorical variables. RESULTS:  A total of 1,849 patients were identified as obese with a drainage procedure, while 12,371 were identified as non-obese. Some 1,746 patients remained in each group after propensity score matching. Thirty-day survival rates were 88.08% in the obese vs. 83.82% in the non-obese cohorts, 90-day survival 85.15% vs. 79.35%, 365-day survival at 80.89% vs. 71.90%, and five-year survival at 64.75% vs. 54.84% (p < 0.0001). The risk difference was -8.02% (95% confidence interval, Cl -11.02, -5.021%); relative risk, RR 0.757, 95% Cl (0.67, 0.841); odds ratio, OR 0.676 (0.583, 0.783); p < 0.0001). Seizures, ventilator dependence, MI, cerebral infarction, tracheostomy, and PEG rates were all non-significant. Obese patients had a higher rate of PE (7.90% vs. 4.47%, p < 0.0001) and DVTs (12.37% vs. 10.02%, p = 0.0278). CONCLUSIONS:  Obesity in patients with cSDH undergoing surgical evacuation is associated with decreased mortality but higher rates of DVT and PE.

Appendicitis and Presence of a Ventriculoperitoneal (VP) Shunt.

INTRODUCTION: Appendicitis can cause ventriculoperitoneal (VP) shunt infection. However, little data is available on the incidence of shunt infections and shunt revisions with appendicitis. Therefore, we sought to determine the rates of shunt infection and revision in patients with VP shunt and appendicitis using large database data and review the literature. METHODS: We used a de-identified database network (TriNetX) to retrospectively query via ICD-10 and current procedural terminology codes to evaluate all patients with the presence of a VP shunt and appendicitis. Primary outcomes included shunt infection and shunt revision at 90 days, with secondary outcomes of sepsis and seizure. RESULTS: 396 patients with VP shunt and subsequent appendicitis were identified. The average age was 27.02+-20.94 years. Shunt infection was identified in 43 (10.859%) patients within 90 days of appendicitis, and shunt externalization or revision was performed in 66 (16.667%) patients. Sepsis was identified in 49 (12.374%) patients and seizures occurred in 56 (14.141%) patients. The literature review revealed eight relevant articles, with 49 total patients. Ten (20.408%) patients had shunts externalized, four of which occurred after shunt infection was identified. Shunt infection occurred in a total of 11 (22.449%) patients. Two (4.082%) patients died, one of which had their shunt externalized pre-emptively, and the other after ventriculitis was identified. Shunt revisions were performed in 16 (32.653%) Conclusion: Our results demonstrate that shunt externalization should be strongly considered in patients with appendicitis, given high shunt infection rates.

Anxiety as a Risk Factor for Postoperative Delirium in Elective Spine Deformity Surgeries: A National Database Study.

Introduction Generalized anxiety disorder has become one of the most prevalent mental health disorders in the United States. In addition, postoperative delirium has been shown to increase hospital stay, increase mortality, and increased healthcare costs. Few studies have looked at the prevalence of postoperative delirium in patients diagnosed with anxiety undergoing elective spinal deformity procedures. The purpose of this study was to determine if anxiety is a risk factor for postoperative delirium in elective spinal deformity surgeries. Methods The authors performed a retrospective analysis using the TriNetX Research Database. Patients diagnosed with kyphosis or lordosis who then underwent elective spinal correction surgeries were identified. This group was then separated based on the diagnosis of a generalized anxiety disorder before the operation versus no diagnosis. Propensity score adjustment, based on mental disorders and other risk factors, was then used to match cohorts on baseline demographics and characteristics. Analysis was performed on the primary outcome of postoperative delirium, with secondary outcomes of upper respiratory tract infections, surgical site infections, sepsis, ventilator dependence, convulsions, stroke, emergency department visits, myocardial infarction, pulmonary embolism, and urinary retention within 30 days after surgery. Results Our search included 1,211 patients with a diagnosis of anxiety and 8,055 patients without anxiety. After propensity score matching, 996 patients remained in each cohort. Statistical analysis showed significant outcomes between the matched cohorts in the anxiety group for postoperative delirium (OR 2.788; 1.587-4.899) and convulsions (OR 1.615; 1.006-2.592). All other outcomes were not significant after propensity score matching. Conclusion These results showed generalized anxiety disorder is a risk factor for postoperative delirium and convulsions after elective spine surgery. Further research is necessary on the effects of mental health disorders on postoperative delirium and other outcomes to better understand the risks in this population.

Mortality Rate of Ischemic Stroke Patients Undergoing Decompressive Hemicraniectomy With Obesity.

Background Obesity has been shown to have a positive mortality benefit in patients undergoing percutaneous coronary intervention and dialysis and those with rheumatoid arthritis, chronic obstructive pulmonary disease, and various wasting diseases. Studies for this mortality benefit in ischemic stroke patients are conflicting and have not been well studied in hemicraniectomy patients. We sought to determine the impact of obesity on outcomes of hemicraniectomy patients. Methods We performed a retrospective case-control database analysis using a multi-institutional database (TriNetX) looking at obese versus non-obese patients with ischemic stroke undergoing hemicraniectomy. Our primary endpoint was mortality. Secondary endpoints included seizure, pulmonary embolism, myocardial infarction (MI), cerebral infarction, deep vein thrombosis, tracheostomy, and percutaneous endoscopic gastrostomy. Cohorts were propensity-score matched for confounders. Results After propensity score matching for basic demographics and common comorbidities, as well as indicators of stroke severity, 646 patients were identified that were obese and had an ischemic stroke with subsequent hemicraniectomy (cohort 1), and 646 patients were identified who were non-obese with ischemic stroke and hemicraniectomy (cohort 2). Thirty-day survival rate was 98.142% in the obese vs. 87.771% in the non-obese cohorts, 90-day survival was 85.15% vs. 79.35%, 180-day survival was 96.44% vs. 84.52%, 365-day survival was 94.272% vs. 81.734%, and five-year survival was 81.889% vs. 75.077%, respectively. At five years, risk difference was -7.276% (95% CI: -11.757, -2.794) and odds ratio was 0.666 (95% CI: 0.510, 0.871) (p = 0.0029). Despite a higher mortality rate, obese patients had a statistically significant increase in pulmonary embolism (11.61% vs. 5.108, p < 0.0001), deep venous thrombosis (16.873% vs. 9.133%, p < 0.0001), and MI (8.824% vs. 5.882%, p = 0.0428). There was no significant difference in intensive care unit length of stay, ventilator dependence, tracheostomy placement, percutaneous endoscopic gastrostomy placement, or intracerebral hemorrhage. Conclusions Despite the increased risk of ischemic stroke, obese patients who undergo hemicraniectomy have decreased mortality rates compared to their non-obese counterparts.

Early Versus Late Tracheostomy in Spontaneous Intracerebral Hemorrhage.

INTRODUCTION: Recent literature supports early tracheostomy (<=7 days) over delayed tracheostomy (>7 days-3 months) to improve overall clinical outcomes for patients admitted with an acute head injury. There is conflicting evidence for the same in hemorrhagic stroke. Using a multi-institutional database, we explored this question in nontraumatic spontaneous intracerebral hemorrhage (sICH) patients. METHODS: We used a de-identified database network (TriNetX's Research Network) to gather information on early tracheostomy (<=7 days) and late tracheostomy (>7d-3 months) in sICH patients. After accounting for the most common comorbidities, we explored the impact of this intervention on multiple patient outcomes including intensive care unit (ICU) length of stay, pneumonia, and mortality at 30, 90, and 365 days. RESULTS: After propensity score matching, a total of 1210 patients were identified for both early tracheostomy (cohort 1) and late tracheostomy (cohort 2) cohorts. The 30-day survival rate was 0.9287 in cohort 1 vs 0.9536 in cohort 2, with a risk difference of 2.39% (95% confidence interval (CI) 0.557%-4.23%; relative risk (RR) 1.54, 95% CI (1.10-2.15); OR 1.577, 95% CI (1.11-2.24); p = 0.006). The 90-day and 365-day end-point survival rates were not statistically different between cohorts. ICU level of care codes were billed an average of 9.76 (SD 8.964) times in cohort 1 vs 14.618 (SD 11.851) in cohort 2 (p<0.0001). At 365 days, there were no differences between the two groups for pulmonary embolism, myocardial infarction, deep venous thrombosis, palliative care consultation, and percutaneous endoscopic gastrostomy tube placement. Cohort 1 had decreased incidence of pneumonia with 665 (54.95%) patients compared to cohort 2 with 725 (59.91%) (RR 0.917, 95% CI (0.856-0.983), OR 0.816, 95% CI (0.695-0.95), p = 0.013). CONCLUSION: Early tracheostomy in sICH patients was associated with decreased pneumonia risk, decreased length of ICU care, and no difference in mortality at 90 and 365 days.

Risk of Glioblastoma Multiforme in Patients Taking Ion Channel Blockers.

Background Ion channels play a role in the development and progression of glioblastoma multiforme. This study investigates the association between the risk of developing glioblastoma multiforme in patients taking these medications. Methods A retrospective propensity score-matched analysis was performed using the TriNetX multinational electronic health record database for patients taking verapamil, digoxin, amiodarone, or diltiazem versus those not taking these medications. The outcome of interest was the incidence of glioblastoma multiforme. Results Verapamil users had an OR of 0.494 (p < 0.0001) of developing glioblastoma versus verapamil non-users. Patients on digoxin had an OR of 0.793 (p = 0.2393), patients on amiodarone had an OR of 0.600 (p = 0.0035), patients on diltiazem had an OR of 0.584 (p < 0.0001), and patients on verapamil, digoxin, amiodarone, or diltiazem had an OR of 0.641 (p < 0.0001) of developing glioblastoma versus patients not taking these medications. Conclusion In patients taking the ion channel blockers diltiazem, amiodarone, or verapamil, the odds of developing glioblastoma multiforme were lower than in patients not taking these medications.