Outpatient anterior cervical discectomy and fusion for cervical disk disease: a prospective consecutive series of 96 patients.

OBJECTIVES: To evaluate surgical complications and clinical outcome in a consecutive series of 96 patients undergoing anterior cervical discectomy and fusion (ACDF) for cervical disk degeneration (CDD) in an outpatient setting. METHODS: Pre-, per-, and postoperative data on patients undergoing single- or two-level outpatient ACDF at the private Oslofjord Clinic were prospectively collected. RESULTS: This study includes 96 consecutive patients with a mean age of 49.1 years. 36/96 had a two-level ACDF. Mean postoperative observation time before discharge was 350 min, and 95/96 were successfully discharged either to their home or to a hotel on the day of surgery. The surgical mortality was 0%, while the surgical morbidity rate was 5.2%. Two (2.1%) patients developed postoperative hematoma, 2 (2.1%) patients experienced postoperative dysphagia, and 1 (1%) experienced deterioration of neurological function. Radicular pain, neck pain, and headache decreased significantly after surgery. 91% of patients were satisfied with the surgery, according to the NASSQ. CONCLUSION: ACDF in carefully selected patients with CDD appears to be safe in the outpatient setting, provided a sufficient postoperative observation period. The clinical outcome and patient satisfaction of outpatients are comparable to that of inpatients.

Craniotomy for brain metastases: a consecutive series of 316 patients.

OBJECTIVE: To assess the incidence of craniotomy for brain metastases, overall survival (OS), surgical mortality, and prognostic factors in a large, contemporary, consecutive series from a well-defined catchment area. MATERIAL AND METHODS: All patients ≥ 18 years who underwent craniotomies for intracranial metastases at Oslo University Hospital, Rikshospitalet and Ullevål, between 2005 and June 30, 2009 were included (n = 316). Patients were identified from our prospectively collected database and a thorough review of all charts to validate the entered data was performed. RESULTS: The annual incidence of first-time craniotomy for a brain metastasis was 2.6/100,000 inhabitants. Patient age ranged from 25 to 87 years (median 64 years). The 30-day mortality rate was 3.8%. Median OS was 9.2 months. Recursive partitioning analysis was class I in 19.6%, class II in 59.2%, and class III in 21.2% with median OS of 16.2, 8.9, and 5.6 months, respectively (P < 0.001). Lung cancer and melanoma were associated with a higher risk (>1% per year) of developing brain metastases. Significant negative prognostic factors were age ≥ 65, a poor performance score, unstable extracranial disease, presence of extracranial metastases, multiplicity, metastasis in eloquent area, and no post-operative radiotherapy. CONCLUSIONS: In this population study, the annual incidence of a first-time craniotomy for a brain metastasis was 2.6/100,000, the 30-day mortality rate was 3.8%, and median OS was 9.2 months. The well-known prognostic factors were confirmed.

Surgical mortality and complications leading to reoperation in 318 consecutive posterior decompressions for cervical spondylotic myelopathy.

OBJECTIVE: To determine surgical mortality, incidence of surgery-related neurological deterioration and incidence of postoperative infection or hematoma requiring reoperation in a consecutive series of 318 patients surgically treated with laminectomy or laminoplasty for cervical spondylotic myelopathy (CSM). MATERIALS AND METHODS: This is a retrospective study of 318 consecutive patients treated with laminectomy or laminoplasty for CSM at Oslo University Hospital in the time period 2003-2008. The defined neurosurgical catchment area for OUS is the southeast region of Norway with 2.7 mill inhabitants. The patient charts were systematically reviewed, focusing primarily on operative notes, postoperative (po) complications, such as po deterioration of neurological function, po hematoma and po infection and neurological function at most recent follow-up. RESULTS: The mean age was 64 years (range 29-90 years). Laminectomy was performed in 310/318 (97.5%) and laminoplasty in 8/318 (2.5%) of the patients. The incidence of laminectomy/laminoplasty for CSM was 2.0/100,000 inhabitants per year. The surgical mortality was 0%, and 37 (11.6%) patients had a deterioration of neurological function in the immediate postoperative period. Four (1.3%) patients were reoperated because of po hematoma. We found a statistically significant association between po hematoma and previous posterior neck surgery and American Association of Anaesthetists (ASA) score. Five (1.6%) patients were reoperated because of postoperative infection. Univariate logistic regression analysis showed a statistically significant association between po infection and the number of levels decompressed. CONCLUSIONS: The incidence of laminectomy/laminoplasty for CSM is 2.0/100,000 inhabitants per year. Surgical mortality, postoperative hematoma and postoperative infection are rare complications of laminectomy/laminoplasty for CSM. Neurological deterioration is not an uncommon complication after posterior decompression for CSM.

Low frequency of VHL germline mutations in Norwegian patients presenting with isolated central nervous system hemangioblastomas--a population-based study.

OBJECTIVES: Explore the genetic and clinical incidence of von Hippel-Lindau disease in patients presenting with isolated central nervous system hemangioblastomas. RESULTS: We report a 3.2% (1/31) and 25% (8/32) incidence of genetic and clinical VHL, respectively. One patient tested positive for a VHL mutation that has not previously been reported. This genotype phenotypically predicts VHL type 2B. We had seven patients with renal cysts. In a total follow-up of 33 person years, none of these cysts progressed to renal cell carcinoma. CONCLUSION: von Hippel-Lindau disease anchored in germline mutations of the VHL gene is rare in the Norwegian population as opposed to clinical VHL disease, which appears to be relatively common in patients with apparently sporadic hemangioblastomas. There exists insufficient data regarding the natural history of patients with renal cysts, which makes it difficult to include or disregard these lesions as an entity of VHL disease.

Overall survival, prognostic factors, and repeated surgery in a consecutive series of 516 patients with glioblastoma multiforme.

OBJECTIVES: To study overall survival (OS), prognostic factors, and repeated surgery in glioblastoma multiforme (GBM). MATERIAL AND METHODS: Retrospective study of 516 consecutive adult patients who underwent primary surgery for a GBM in year 2003-2008. RESULTS: Median age at primary surgery was 63.7 years (range 18.0-88.0). Median OS was 9.9 months. Age > 60 years, poor preoperative ECOG score, bilateral tumor, biopsy rather than resection, and no temozolomide chemoradiotherapy were negative risk factors. Repeat surgery was performed in 65 patients (13%). Median time between first and second surgery was 7 months. Indications for second surgery were increasing neurological deficits (35.4%), raised ICP (33.8%), asymptomatic but reoperated because of tumor progression verified on MRI (20.0%), and epileptic seizures (11%). Patients who underwent repeated surgery had longer OS; 18.4 months vs 8.6 months (P < 0.001). CONCLUSIONS: OS for adult GBM patients was 9.9 months. Negative prognostic factors were increasing age, poor neurological function, bilateral tumor involvement, biopsy instead of resection, and RT alone compared to temozolomide chemoradiotherapy. Our rate of repeated surgery for GBM was 13% and the main indications for second surgery were raised ICP and increasing neurological deficits. In a carefully selected group of patients, repeat surgery significantly prolongs OS.

Intracranial tumor surgery in patients >70 years of age: is clinical practice worthwhile or futile?

OBJECTIVES: To study survival and functional outcome after intracranial tumor surgery in elderly patients. MATERIALS AND METHODS: This is a retrospective study of 289 consecutive patients of age > or =70 years, who underwent primary surgery (resection or biopsy) in the time period 2003-2007 for an intracranial tumor (87 astrocytomas, 79 meningiomas, 62 brain metastases, 33 pituitary adenomas and 28 other tumors). RESULTS: The surgical mortality was 2.8%. Overall survival at 6 months, 1, 2 and 5 years was 73%, 57%, 46% and 38% respectively. Histology, pre-operative Eastern Cooperative Oncology Group (ECOG) performance score and resection, as opposed to biopsy, were significantly associated with survival. Gender, age and American Association of Anaesthetists (ASA) score were not significantly related to survival. One-year survival after surgery for astrocytoma, meningioma, brain metastases and pituitary adenoma were 24%, 94%, 31% and 96% respectively. More than 85% of the patients who were alive 6 months after surgery had a stable or improved ECOG score compared with their pre-operative score. CONCLUSIONS: Surgery for intracranial tumors in selected elderly patients is worthwhile, not futile. Age alone should not be used as a selection criterion for treatment.

Aspects of intracerebral hematomas--an update.

BACKGROUND: In Norway, there are approximately 16000 strokes each year and 15% of these are caused by intracerebral hematomas. Intracerebral hemorrhage (ICH) results from the rupture of blood vessels within the brain parenchyma. ICH occurs as a complication of several diseases, the most prevalent of which is chronic hypertension. When hemorrhage develops in the absence of a pre-existing vascular malformation or brain parenchymal lesion, it is denoted primary ICH. Secondary ICH refers to hemorrhage complicating a pre-existing lesion. Primary ICH is the most common type of hemorrhagic stroke, accounting for approximately 10% of all strokes. Despite aggressive management strategies, the 30-day mortality remains high, at almost 50%, with the majority of deaths occurring within the first 2 days. At 6 months, only 20-30% achieve independent status. MATERIAL AND METHODS: This article is based on clinical experience, modern therapeutic guidelines for the treatment of intracerebral hematomas and up-to-date medical literature found in Medline. The article discusses the pathophysiology, clinical aspects, treatment, and the prognosis of intracerebral hematomas. RESULTS AND DISCUSSION: Advances in diagnosis, prognosis, pathophysiology, and treatment over the past few decades have significantly advanced our knowledge of ICH; however, much work still needs to be carried out. Future genetic and epidemiologic studies will help identify at-risk populations and hopefully allow for primary prevention. Randomized controlled studies focusing on novel therapeutics should help to minimize secondary injury and hopefully improve morbidity and mortality.

Fatty acid composition of spermatozoa is associated with BMI and with semen quality.

High body mass index (BMI) is negatively associated with semen quality. In addition, the composition of fatty acids of spermatozoa has been shown to be important for their function. The aim of the study was to examine the association between BMI and the composition of spermatozoa fatty acids in men spanning a broad BMI range. We also analysed the relation between fatty acid composition of spermatozoa and semen characteristics, and the relationship between serum fatty acids and spermatozoa fatty acids. One hundred forty-four men with unknown fertility status were recruited from the general population, from couples with identified female infertility and from morbid obesity centres. Standard semen analysis (WHO) and sperm DNA integrity (DFI) analysis were performed. Fatty acid compositions were assessed by gas chromatography. When adjusted for possible confounders, BMI was negatively associated with levels of sperm docosahexaenoic acid (DHA) (p < 0.001) and palmitic acid (p < 0.001). The amount of sperm DHA correlated positively with total sperm count (r = 0.482), sperm concentration (r = 0.469), sperm vitality (r = 0.354), progressive sperm motility (r = 0.431) and normal sperm morphology (r = 0.265). A negative association was seen between DHA levels and DNA fragmentation index (r = -0.247). Levels of spermatozoa palmitic acid correlated positively with total sperm count (r = 0.227), while levels of linoleic acid correlated negatively (r = -0.254). When adjusted for possible confounders, only the levels of arachidonic acid showed positive correlation between spermatozoa and serum phospholipids (r = 0.262). Changes in the fatty acid composition of spermatozoa could be one of the mechanisms underlying the negative association between BMI and semen quality. The relationship between fatty acids of spermatozoa and serum phospholipids was minor, which indicates that BMI affects fatty acid composition of spermatozoa through regulation of fatty acid metabolism in the testis. The role of dietary intake of fatty acids on the spermatozoa fatty acid composition remains to be elucidated.

The organization of heart services. Part one: The elements of the successful heart services organization.

The most successful heart programs have been able to bring together the interests of the physicians and the hospital and its personnel in such a way that the practitioners determine that their individual interests are best met through the program.

The organization of heart services. Part Two: Structural alternatives for the successful heart services organization.

This article provides a framework of the various models currently available to form a heart institute that is designed to enhance the position of the providers with managed care and other third-party payers. Each model has components that are similar: Governance and management are provided by an advisory board or steering committee. The board is typically comprised of representatives of both the physicians and the hospital. Daily management is provided by a professional manager, such as an executive director. The ability of the model to locate, negotiate and enter into contracts for the providers is determined by the amount of integration of services provided by the participants. Each of the models discussed in sequence represents increasing integration; therefore, the cardiac IPO has more integration--particularly if it offers a new service such as capitation to the market--than the service-line approach. The ICHO has the most integration of the models presented. This form of organization will be addressed more completely in Part Four of this series. Part Three will discuss PHO models in-depth as well as address certain legal requirements that should be considered when developing a new, integrated PHO entity.

Preparing for Medicare single-provider contracting: becoming a center of excellence.

Hospitals and physicians participating in the CABG Surgery Demonstration Project will certainly have an advantage over the competition. Although HCFA has not issued specifics of the process to be applied for the expansion of the project, a review of the program goals and events leading the initial selection is instructive.

Heart centers 2000. Part Three: The challenge of excellence.

Healthcare is becoming a mature market from the perspective of "product life cycle" analysis. Mature markets are distinguished by, among other things, expanding competition and increasing emphasis in the market on quality and cost. The cardiac market is the most mature of all aspects of healthcare and, as such, is the most competitive of all healthcare market segments. This is the third in a three-part series on heart centers of the future. The first part dealt with the trends in the cardiac market and the second part focused on the management of change. This article addresses excellence applied to the management of cardiovascular centers over the next decade. Because of the highly evolved nature of the cardiac market, competitive forces will require excellence in terms of service delivery, quality, cost and organization.

The organization of heart services. Part three: Building a cardiac PHO.

This article has examined some of the legal requirements for establishing a PHO or a SPHO. These guidelines have been presented in a generalized format. Legal counsel should be retained prior to developing a PHO to ensure that applicable legal statutes at the state, local and national level are met. Various organizational models have been presented for developing the PHO. The PHO entity allows the physicians and the hospital a single entity, representative of both parties, to locate, negotiate and enter into contracts on their behalf. The PHO can allocate revenues among the parties based on the amount of risk and services provided. There are some questions as to the long-term viability of PHOs given the regulatory changes occurring in the healthcare arena. Regardless of the regulatory changes that may occur, PHOs provide a vehicle for enhancing the relationship between a hospital and its physicians. PHOs are often a step in the process of developing a fully integrated healthcare organization. The PHO provides a forum for developing and enhancing trust and collaboration among the physicians and between the physicians and the hospital. Trust and collaboration will be key ingredients in the future as physicians and hospitals work more closely together in providing high-quality, cost-effective care that meets the patient market needs and expectations. Part Four of this series will discuss the fully integrated healthcare organization.

Positioning must have new place in health arena.

Positioning is a marketing concept that has growing application in health care. Medical administrators must look at the traditional definition of the term--the placement rather than the modification of services--in marketing speciality services competitively. The author describes the forces impacting health care, prompting positioning of services.

The medical staff of the future.

Reinventing the medical staff is a process that has been hinted at, but not yet pursued in any full scale effort. Hospitals have the most to lose by maintaining the status quo and the most to gain by initiating a reconsideration of their relationships to physicians. This article explores the underlying need for change, examines alternative models and recommends action for implementing change within the medical staff.