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Mandel EI, Maloney FL, Pertsch NJ, Gass JD, Sanders JJ, Bernacki RE, Block SD. A Pilot Study of the Serious Illness Conversation Guide in a Dialysis Clinic. Am J Hosp Palliat Care 2023; 40:1106-1113. [PMID: 36708263 DOI: 10.1177/10499091221147303] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Clinician-led conversations about future care priorities occur infrequently with end-stage renal disease (ESRD) patients on dialysis. This was a pilot study of structured serious illness conversations using the Serious Illness Conversation Guide (SICG) in a single dialysis clinic to assess acceptability of the approach and explore conversation themes and potential outcomes among patients with ESRD. Twelve individuals with ESRD on dialysis from a single outpatient dialysis clinic participated in this study. Participants completed a baseline demographics survey, engaged in a clinician-led structured serious illness conversation, and completed an acceptability questionnaire. Conversations were recorded, transcribed and thematically analyzed. The average age of participants was 68.8 years. The conversations averaged 20:53 in length. Ten participants (83%) felt that the conversation was held at the right time in their clinical course and eleven participants (91%) felt that it was worthwhile. Most participants (73%) reported neutral feelings about clinician use of a printed guide. Eleven participants (91%) reported no change in anxiety about their illness following the conversation, and five participants (42%) reported that the conversation increased their hopefulness about future quality of life. Thematic analysis revealed common perspectives on dialysis including that participants view in-center hemodialysis as temporary, compartmentalize their kidney disease, perceive narrowed life experiences and opportunities, and believe dialysis is their only option. This pilot study suggests that clinician-led structured serious illness conversations may be acceptable to patients with ESRD on dialysis. The themes identified can inform future serious illness conversations with dialysis patients.
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Affiliation(s)
- Ernest I Mandel
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Francine L Maloney
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Nathan J Pertsch
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
| | | | - Justin J Sanders
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Rachelle E Bernacki
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Susan D Block
- Ariadne Labs, Brigham and Women's Hospital and Harvard TH Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Departments of Psychiatry and Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Hagan MJ, Pertsch NJ, Leary OP, Ganga A, Sastry R, Xi K, Zheng B, Behar M, Camara-Quintana JQ, Niu T, Sullivan PZ, Abinader JF, Telfeian AE, Gokaslan ZL, Oyelese AA, Fridley JS. Influence of socioeconomic factors on discharge disposition following traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States. N Am Spine Soc J 2022; 12:100186. [PMID: 36479003 PMCID: PMC9720595 DOI: 10.1016/j.xnsj.2022.100186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/04/2022] [Accepted: 11/19/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Discharge to acute rehabilitation is strongly correlated with functional recovery after traumatic injury, including spinal cord injury (SCI). However, services such as acute care rehabilitation and Skilled Nursing Facilities (SNF) are expensive. Our objective was to understand if high-cost, resource-intensive post-discharge rehabilitation or alternative care facilities are utilized at disparate rates across socioeconomic groups after SCI. METHODS We performed a cohort analysis using the National Trauma Data Bank® tabulated from 2012-2016. Eligible patients had a diagnosis of cervical or thoracic spine fracture with spinal cord injury (SCI) and were treated surgically. We evaluated associations of sociodemographic and psychosocial variables with non-home discharge (e.g., discharge to SNF, other healthcare facility, or intermediate care facility) via multivariable logistic regression while correcting for injury severity and hospital characteristics. RESULTS We identified 3933 eligible patients. Patients who were older, male (OR=1.29 95% Confidence Interval [1.07-1.56], p=.007), insured by Medicare (OR=1.45 [1.08-1.96], p=.015), diagnosed with a major psychiatric disorder (OR=1.40 [1.03-1.90], p=.034), had a higher Injury Severity Score (OR=5.21 [2.96-9.18], p<.001) or a lower Glasgow Coma Score (3-8 points, OR=2.78 [1.81-4.27], p<.001) had a higher chance of a non-home discharge. The only sociodemographic variable associated with lower likelihood of utilizing additional healthcare facilities following discharge was uninsured status (OR=0.47 [0.37-0.60], p<.001). CONCLUSIONS Uninsured patients are less likely to be discharged to acute rehabilitation or alternative healthcare facilities following surgical management of SCI. High out-of-pocket costs for uninsured patients in the United States may deter utilization of these services.
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Affiliation(s)
- Matthew J. Hagan
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
| | - Nathan J. Pertsch
- Department of Neurosurgery, Rush University Medical Center, 600 S. Paulina St, Chicago, IL 60612, USA
| | - Owen P. Leary
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Arjun Ganga
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Rahul Sastry
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Kevin Xi
- Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA
| | - Bryan Zheng
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
| | - Mark Behar
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
| | - Joaquin Q. Camara-Quintana
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Tianyi Niu
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Patricia Zadnik Sullivan
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Jose Fernandez Abinader
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Albert E. Telfeian
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Ziya L. Gokaslan
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Adetokunbo A. Oyelese
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
| | - Jared S. Fridley
- The Warren Alpert School of Medicine, Brown University, 222 Richmond St, Providence, RI 02903, USA
- Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, APC6, Providence, RI 02903, USA
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Hagan MJ, Pertsch NJ, Leary OP, Sastry R, Ganga A, Xi K, Zheng B, Kondamuri NS, Camara-Quintana JQ, Niu T, Sullivan PZ, Abinader JF, Telfeian AE, Gokaslan ZL, Oyelese AA, Fridley JS. Influence of Sociodemographic and Psychosocial Factors on Length of Stay After Surgical Management of Traumatic Spine Fracture with Spinal Cord Injury. World Neurosurg 2022; 166:e859-e871. [PMID: 35940503 DOI: 10.1016/j.wneu.2022.07.128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Identifying patients at risk of increased health care resource utilization is a valuable opportunity to develop targeted preoperative and perioperative interventions. In the present investigation, we sought to examine patient sociodemographic factors that predict prolonged length of stay (LOS) after traumatic spine fracture. METHODS We performed a cohort analysis using the National Trauma Data Bank tabulated during 2012-2016. Eligible patients were those who were diagnosed with cervical or thoracic spine fracture with spinal cord injury and who were treated surgically. We evaluated the effects of sociodemographic as well as psychosocial variables on LOS by negative binomial regression and adjusted for injury severity, injury mechanism, and hospital characteristics. RESULTS We identified 3856 eligible patients with a median LOS of 9 days (interquartile range, 6-15 days). Patients in older age categories, who were male (incidence rate ratio (IRR), 1.05; 95% confidence interval [CI], 1.01-1.09), black (IRR, 1.12; CI, 1.05-1.19) or Hispanic (IRR, 1.09; CI, 1.03-1.16), insured by Medicaid (IRR, 1.24; CI, 1.17-1.31), or had a diagnosis of alcohol use disorder (IRR, 1.12; CI, 1.06-1.18) were significantly more likely to have a longer LOS. In addition, patients with severe injury on Injury Severity Score (IRR, 1.32; CI, 1.14-1.53) and lower Glasgow Coma Scale (GCS) scores (GCS score 3-8, IRR, 1.44; CI, 1.35-1.55; GCS score 9-11, IRR, 1.40; CI, 1.25-1.58) on admission had a significantly lengthier LOS. Patients admitted to a hospital in the Southern United States (IRR, 1.09; CI, 1.05-1.14) had longer LOS. CONCLUSIONS Socioeconomic factors such as race, insurance status, and alcohol use disorder were associated with a prolonged LOS after surgical management of traumatic spine fracture with spinal cord injury.
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Affiliation(s)
- Matthew J Hagan
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Nathan J Pertsch
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Owen P Leary
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Rahul Sastry
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Arjun Ganga
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Kevin Xi
- Brown University School of Public Health, Providence, Rhode Island, USA
| | - Bryan Zheng
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | | | - Joaquin Q Camara-Quintana
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Tianyi Niu
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Patricia Zadnik Sullivan
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jose Fernandez Abinader
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Albert E Telfeian
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Adetokunbo A Oyelese
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jared S Fridley
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA.
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Pertsch NJ, Garcia CM, Daniel Y, Phillips RK, Sagaityte E, Hagan MJ, Toms SA, Weil RJ. Outcomes for Adults with Metabolic Syndrome Undergoing Elective Carotid Endarterectomy. World Neurosurg 2022; 163:e146-e155. [PMID: 35338016 DOI: 10.1016/j.wneu.2022.03.082] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Metabolic syndrome (MetS) is a disorder characterized by a constellation of cardiometabolic risk factors including abdominal obesity, dyslipidemia, hypertension, and glucose intolerance that has been associated with adverse perioperative outcomes. We evaluated outcomes for patients with MetS after carotid endarterectomy (CEA) in the largest population to date. METHODS We performed a matched cohort analysis using clinical data from 2012 to 2018 in the American College of Surgeons National Surgical Quality Improvement Program. We used propensity scores to match patients to attain covariate balance and used logistic regression to assess odds of unfavorable outcomes, including a predefined primary outcome of composite cardiovascular incident. RESULTS We identified 50,423 eligible adult patients, of whom 14.2% qualified for MetS (n = 7156). Patients with MetS tended to have CEA at an earlier age, more functional dependence, and longer operative durations. After matching, MetS remained associated with the primary outcome of combined cardiovascular incident (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.18-1.72; P < 0.001), stroke (OR, 1.44; 95% CI, 1.12-1.85; P = 0.004), prolonged length of stay (OR, 1.31; 95% CI, 1.18-1.44; P < 0.001), and discharge to facility (OR, 1.32; 95% CI, 1.08-1.61; P = 0.007). We also found that obesity alone is protective against combined cardiovascular incident, whereas hypertension with diabetes and MetS increase odds of a cardiovascular complication. CONCLUSIONS Metabolic syndrome is associated with adverse outcomes for adult patients undergoing elective CEA.
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Affiliation(s)
- Nathan J Pertsch
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.
| | - Catherine M Garcia
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Yonathan Daniel
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Ronald K Phillips
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Emilija Sagaityte
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Matthew J Hagan
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Steven A Toms
- The Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Robert J Weil
- Department of Neurosurgery, Southcoast Health, North Dartmouth, Massachusetts, USA
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5
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Sastry RA, Pertsch NJ, Sagaityte E, Poggi JA, Toms SA, Weil RJ. In Reply: Early Outcomes After Carotid Endarterectomy and Carotid Artery Stenting: A Propensity-Matched Cohort Analysis. Neurosurgery 2022; 91:e16-e17. [PMID: 35467598 DOI: 10.1227/neu.0000000000002006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/28/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Rahul A Sastry
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Nathan J Pertsch
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Emilija Sagaityte
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Jonathan A Poggi
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Steven A Toms
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Rhode Island Hospital, Lifespan Health System, Providence, Rhode Island, USA
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Lifespan Health System, Providence, Rhode Island, USA.,Southcoast Health Brain & Spine, Dartmouth, Massachusetts, USA
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Bajaj A, Sastry R, Wang E, Pertsch NJ, Weil R. 358 Cost Analysis of Complications After Craniotomy for Brain Tumor. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Hagan MJ, Pertsch NJ, Leary OP, Zheng B, Camara-Quintana JQ, Niu T, Mueller K, Boghani Z, Telfeian AE, Gokaslan ZL, Oyelese AA, Fridley JS. Influence of psychosocial and sociodemographic factors in the surgical management of traumatic cervicothoracic spinal cord injury at level I and II trauma centers in the United States. J Spine Surg 2021; 7:277-288. [PMID: 34734132 DOI: 10.21037/jss-21-37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/30/2021] [Indexed: 11/06/2022]
Abstract
Background Socioeconomic factors can bias clinician decision-making in many areas of medicine. Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, and major psychiatric disorder are emerging as potential sources of conscious and unconscious bias. We hypothesized that these psychosocial factors, in addition to socioeconomic factors, may impact the decision to operate on patients with a traumatic cervicothoracic fracture and associated spinal cord injury (SCI). Methods We performed a cohort analysis using clinical data from 2012-2016 in the American College of Surgeons (ACS) National Trauma Data Bank at academic level I and II trauma centers. Patients were eligible if they had a diagnosis of cervicothoracic fracture with SCI. Using ICD codes, we evaluated baseline characteristics including race; insurance status; diagnosis of alcoholism, substance abuse, or major psychiatric disorder; admission drug screen and blood alcohol level; injury characteristics and severity; and hospital characteristics including geographic region, non-profit status, university affiliation, and trauma level. Factors significantly associated with surgical intervention in univariate analysis were eligible for inclusion in multivariate logistic regression. Results We identified 6,655 eligible patients, of whom 62% underwent surgical treatment (n=4,137). Patients treated non-operatively were more likely to be older; be female; be Black or Hispanic; have Medicare, Medicaid, or no insurance; have been assaulted; have been injured by a firearm; have thoracic fracture; have less severe injuries; have severe TBI; be treated at non-profit hospitals; and be in the Northeast or Western U.S. (all P<0.01). After adjusting for confounders in multivariate analysis, only insurance status remained associated with operative treatment. Medicaid patients (OR=0.81; P=0.021) and uninsured patients (OR=0.63; P<0.001) had lower odds of surgery relative to patients with private insurance. Injury severity and facility characteristics also remained significantly associated with surgical management following multivariate regression. Conclusions Psychosocial characteristics such as diagnosis of alcoholism, substance abuse, or psychiatric illness do not appear to bias the decision to operate after traumatic cervicothoracic fracture with SCI. Baseline sociodemographic imbalances were explained largely by insurance status, injury, and facility characteristics in multivariate analysis.
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Affiliation(s)
- Matthew J Hagan
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Nathan J Pertsch
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Owen P Leary
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Bryan Zheng
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Joaquin Q Camara-Quintana
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Tianyi Niu
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Kyle Mueller
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Zain Boghani
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Albert E Telfeian
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Ziya L Gokaslan
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Adetokunbo A Oyelese
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Jared S Fridley
- The Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
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McHayle A, Pertsch NJ, Toms SA, Weil RJ. Operative duration and early outcomes in patients having a supratentorial craniotomy for brain tumor: A propensity matched analysis. J Clin Neurosci 2021; 92:207-214. [PMID: 34509254 DOI: 10.1016/j.jocn.2021.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 08/04/2021] [Accepted: 08/05/2021] [Indexed: 11/25/2022]
Abstract
It is unclear how variations in operative duration affect outcomes after craniotomy for supratentorial brain tumor. We characterized three populations of patients with typical, shorter, and longer durations of craniotomy for supratentorial brain tumor using prospectively collected clinical data from 16,335 patients in the 2012-2018 ACS National Surgical Quality Improvement Program (NSQIP) database. We compared baseline characteristics including demographics, comorbidities, tumor type, and operative features. We used propensity score matching to attain covariate balance and logistic regression to assess odds of unfavorable outcomes. Patients with the shortest operation durations tended to be older, with fewer males, higher ASA class, more metastatic brain tumors, more medical comorbidities, and less use of intraoperative microscope or ultrasound. Patients with the longest operative durations tended to be younger, with more males, fewer non-white minorities, more obesity, lower ASA classes, more intrinsic brain tumors, fewer medical comorbidities, fewer emergency operations, and increased use of intraoperative microscope. For patients with the shortest operations, after matching, we observed significantly decreased odds of prolonged length-of-stay (LOS), major complication, any complication, reoperation, and discharge to a facility; however, there was a significantly increased risk of 30-day mortality. For patients with the longest operations, after matching, we observed significantly increased odds of prolonged LOS; minor, major, and any complication; discharge to facility; and 30-day reoperation. After matching to balance baseline characteristics, operative duration has implications for outcomes following craniotomy for supratentorial brain tumor.
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Affiliation(s)
- Allison McHayle
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States.
| | - Nathan J Pertsch
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, United States
| | - Steven A Toms
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
| | - Robert J Weil
- Department of Neurosurgery, Southcoast Brain & Spine, North Dartmouth, MA, United States
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Sastry RA, Pertsch NJ, Sagaityte E, Poggi JA, Toms SA, Weil RJ. Early Outcomes After Carotid Endarterectomy and Carotid Artery Stenting: A Propensity-Matched Cohort Analysis. Neurosurgery 2021; 89:653-663. [PMID: 34320217 DOI: 10.1093/neuros/nyab250] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 06/17/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Carotid endarterectomy (CEA) and carotid artery stenting (CAS) represent options to treat many patients with carotid stenosis. Although randomized trial data are plentiful, estimated rates of morbidity and mortality for both CEA and CAS have varied substantially. OBJECTIVE To evaluate rates of adverse outcomes after CAS and CEA in a large national database. METHODS We analyzed 84 191 adult patients undergoing elective, nonemergent CAS (n = 81 361) or CEA (n = 2830), from 2011 to 2018, in the American College of Surgeons' National Surgical Quality Improvement Program database. Odds of adverse outcomes (30-d rates of stroke, myocardial infarction (MI), cardiac arrest, prolonged length of stay (LOS), readmission, reoperation, and mortality) were evaluated in propensity-matched (n = 2821) cohorts through logistic regression. RESULTS In the propensity-matched cohorts, CAS had increased odds of periprocedural stroke (odds ratio [OR] 1.97, 95% CI 1.32-2.95) and decreased odds of cardiac arrest (OR 0.33, 95% CI 0.13-0.84) and 30-d reoperation (OR 0.59, 95% CI 0.44-0.80) compared to CEA. Relative odds of MI, prolonged LOS, discharge to destination other than home, 30-d readmission, or 30-d mortality were statistically similar. In the unmatched patient population, rates of adverse outcomes with CEA were constant over time; however, for CAS, rates of stroke increased over time. In both the matched and unmatched patient cohorts, patients 70 yr and older had lower rates of post-procedural stroke with CEA, but not with CAS, compared to younger patients. CONCLUSION In a propensity-matched analysis of a large, prospectively collected, national, surgical database, CAS was associated with increased odds of periprocedural stroke, which increased over time. Rates of MI and death were not significantly different between the 2 procedures.
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Affiliation(s)
- Rahul A Sastry
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Nathan J Pertsch
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Emilija Sagaityte
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Jonathan A Poggi
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Steven A Toms
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Rhode Island Hospital, Lifespan Health System, Providence, Rhode Island, USA
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Lifespan Health System, Providence, Rhode Island, USA
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Liu DD, Rivera-Lane K, Leary OP, Pertsch NJ, Niu T, Camara-Quintana JQ, Oyelese AA, Fridley JS, Gokaslan ZL. Supplementation of Screw-Rod C1-C2 Fixation With Posterior Arch Femoral Head Allograft Strut. Oper Neurosurg (Hagerstown) 2021; 20:226-231. [PMID: 33269389 DOI: 10.1093/ons/opaa336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/10/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Numerous C1-C2 fixation techniques exist for the treatment of atlantoaxial instability. Limitations of screw-rod and sublaminar wiring techniques include C2 nerve root sacrifice and dural injury, respectively. We present a novel technique that utilizes a femoral head allograft cut with a keyhole that rests posteriorly on the arches of C1 and C2 and straddles the C2 spinous process, secured by sutures. OBJECTIVE To offer increased fusion across C1-C2 without the passage of sublaminar wiring or interarticular arthrodesis. METHODS A total of 6 patients with atlantoaxial instability underwent C1-C2 fixation using our method from 2015 to 2016. After placement of a C1-C2 screw/rod construct, a cadaveric frozen femoral head allograft was cut into a half-dome with a keyhole and placed over the already decorticated dorsal C1 arch and C2 spinous process. Notches were created in the graft and sutures were placed in the notches and around the rods to secure it firmly in place. RESULTS The femoral head's shape allowed for creation of a graft that provides excellent surface area for fusion across C1-C2. There were no intraoperative complications, including dural tears. Postoperatively, no patients had sensorimotor deficits, pain, or occipital neuralgia. 5 patients demonstrated clinical resolution of symptoms by 3 mo and radiographic (computed tomography) evidence of fusion at 1 yr. One patient had good follow-up at 1 mo but died due to complications of Alzheimer disease. CONCLUSION The posterior arch femoral head allograft strut technique with securing sutures is a viable option for supplementing screw-rod fixation in the treatment of complex atlantoaxial instability.
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Affiliation(s)
- David D Liu
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Kendall Rivera-Lane
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Owen P Leary
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Nathan J Pertsch
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Tianyi Niu
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Joaquin Q Camara-Quintana
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Jared S Fridley
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Ziya L Gokaslan
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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11
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Darveau SC, Pertsch NJ, Toms SA, Weil RJ. Short term outcomes associated with patients requiring blood transfusion following elective laminectomy and fusion for lumbar stenosis: A propensity-matched analysis. J Clin Neurosci 2021; 90:184-190. [PMID: 34275547 DOI: 10.1016/j.jocn.2021.05.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/25/2021] [Accepted: 05/27/2021] [Indexed: 12/01/2022]
Abstract
Perioperative blood transfusion has been associated with poor outcomes but the impacts of transfusion after fusion for lumbar stenosis have not been well-described. We assessed this effect in a large cohort of patients from 2012 to 2018 in the National Surgical Quality Improvement Program (NSQIP). We evaluated baseline characteristics including demographics, comorbidities, hematocrit, and operative characteristics. We generated propensity scores using baseline characteristics and patients were matched to approximate randomization. We assessed odds of 30-day outcomes including prolonged length-of-stay (LOS), complications, discharge to facility, readmission, reoperation, and death using logistic regression. We identified 16,329 eligible patients who underwent lumbar fusion for stenosis; 1,926 (11.8%) received a transfusion. Before matching, there were multiple differences in baseline covariates including age, gender, BMI, ASA class, medical comorbidities, hematocrit, coagulation indices, platelets, operative time, fusion technique, number of levels fused, and osteotomy. However, after matching, no significant differences remained. In the matched cohorts, transfusion was associated with increased prolonged LOS (OR 1.66, 95% CI 1.45-1.91, p < 0.001), minor complication (OR 1.60, 95% CI 1.20-2.12, p = 0.001), major complication (OR 1.51, 95% CI 1.16-1.98, p = 0.003), any complication (OR 1.54, 95% CI 1.24-1.92, p < 0.001), discharge to facility (OR 1.70, 95% CI 1.48-1.95, p < 0.001), 30-day readmission (OR 1.56, 95% CI 1.23-1.99, p < 0.001), and 30-day reoperation (OR 1.85, 95% CI 1.35-2.53, p < 0.001). Although transfusion is performed based on perceived clinical need, this study contributes to growing evidence that it is important to balance the risks of perioperative blood transfusion with its benefits.
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Affiliation(s)
- Spencer C Darveau
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States.
| | - Nathan J Pertsch
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States
| | - Steven A Toms
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
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12
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Perla KMR, Pertsch NJ, Leary OP, Garcia CM, Tang OY, Toms SA, Weil RJ. Outcomes of infratentorial cranial surgery for tumor resection in older patients: An analysis of the National Surgical Quality Improvement Program. Surg Neurol Int 2021; 12:144. [PMID: 33948314 PMCID: PMC8088538 DOI: 10.25259/sni_25_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/09/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Poorer outcomes for infratentorial tumor resection have been reported. There is a lack of large multicenter analyses describing infratentorial surgery outcomes in older patients. We characterized outcomes in patients aged ≥65 years undergoing infratentorial cranial surgery. Methods: The National Surgical Quality Improvement Project database was queried from 2012 to 2018 for patients ≥18 years undergoing elective infratentorial cranial surgery for tumor resection. Patients were grouped into 65–74 years, ≥75 years, and 18–64 years cohorts. Multivariable regressions compared outcome measures. Results: Of 2212 patients, 28.3% were ≥65 years, of whom 24.8% were ≥75 years. Both older subpopulations had worse American Society of Anesthesiologists classification compared to controls (P < 0.01) and more comorbidities. Patients 65–74 and ≥75 years had higher rates of major complication (adjusted odds ratio [aOR] = 1.77, 95% CI = 1.13–2.79 and aOR = 3.44, 95% CI = 1.96–6.02, respectively), prolonged length of stay (LOS) (aOR = 1.89, 95% CI = 1.15–3.12 and aOR = 3.00, 95% CI = 1.65–5.44, respectively), and were more likely to be discharged to a location other than home (aOR = 2.43, 95% CI =1.73–3.4 and aOR = 3.41, 95% CI = 2.18–5.33, respectively) relative to controls. Patients ≥75 had higher rates of readmission (aOR = 1.86, 95% CI = 1.13–3.08) and mortality (aOR = 3.28, 95% CI = 1.21–8.89) at 30 days. Conclusion: Patients ≥65 years experienced more complications, prolonged LOS, and were less often discharged home than adults <65 years. Patients ≥75 years had higher rates of 30-day readmission and mortality. There is a need for careful preoperative optimization in older patients undergoing infratentorial tumor cranial surgery.
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Affiliation(s)
- Krissia M Rivera Perla
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, United States
| | - Nathan J Pertsch
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, United States
| | - Owen P Leary
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, United States
| | - Catherine M Garcia
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, United States
| | - Oliver Y Tang
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, United States
| | - Steven A Toms
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Rhode Island Hospital, United States
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Rhode Island, United States
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13
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Pertsch NJ, Darveau SC, Tang OY, Toms SA, Weil RJ. Urinary Tract Infection after Elective Spine Surgery: Timing, Predictive Factors, and Outcomes. Spine (Phila Pa 1976) 2021; 46:337-346. [PMID: 33534444 DOI: 10.1097/brs.0000000000003794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE The aim of this study was to investigate risk factors associated with the timing of urinary tract infection (UTI) after elective spine surgery, and to determine whether postoperative UTI timing affects short-term outcomes. SUMMARY OF BACKGROUND DATA Urinary tract infection (UTI) is a common post-surgical complication; however, the predominant timing, location, and potential differential effects have not been carefully studied. METHODS We analyzed elective spine surgery patients from 2012 to 2018 in the ACS National Surgical Quality Improvement Program (NSQIP). We grouped patients with postoperative UTI by day of onset relative to discharge, to create cohorts of patients who developed inpatient UTI and post-discharge UTI. We compared both UTI cohorts with a control (no UTI) population and with each other to identify differences in baseline characteristics including demographic, comorbidity and operative factors. We performed multivariate logistic regression to identify predictors of UTI in each cohort and to assess adjusted risks of poor outcomes associated with UTI timing. RESULTS A total of 289,121 patients met inclusion criteria and 0.88% developed UTI (n = 2553). Only 31.6% of UTIs occurred before discharge (n = 806), with 68.4% occurring after discharge (n = 1747). The inpatient UTI cohort had significantly longer operative time, more fusion procedures, more posterior procedures, and more procedures involving the lumbar levels than the post-discharge cohort. Predictors of inpatient UTI included procedure type, spine region, and approach. Predictors of post-discharge UTI included length-of-stay and discharge destination. Both UTI cohorts were significantly associated with sepsis; however, post-discharge UTI carried a higher odds (adjusted odds ratio [aOR] = 24.90, 95% confidence interval [CI] = 21.05-29.45, P < 0.001 vs. aOR = 14.31, 95% CI = 11.09-18.45, P < 0.001). Inpatient UTI was not associated with 30-day readmission, although post-discharge UTI was (aOR = 8.23, 95% CI = 7.36-9.20, P < 0.001). Conversely, inpatient UTI was associated with increased odds of 30-day mortality (aOR = 3.23, 95% CI = 1.62-6.41, P = 0.001), but post-discharge UTI was not. CONCLUSION Predictive factors and outcomes differ based on timing of UTI after elective spine surgery. Before discharge, procedure -specific details predict UTI, but after discharge they do not. These findings suggest that traditional thinking about UTI prevention may need modification.Level of Evidence: 3.
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Affiliation(s)
- Nathan J Pertsch
- The Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Spencer C Darveau
- The Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Oliver Y Tang
- The Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Steven A Toms
- The Warren Alpert School of Medicine, Brown University, Providence, RI
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI
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14
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Pertsch NJ, Leary OP, Camara-Quintana JQ, Liu DD, Niu T, Woo AS, Ng TT, Oyelese AA, Fridley JS, Gokaslan ZL. A modern multidisciplinary approach to a large cervicothoracic chordoma using staged en bloc resection with intraoperative image-guided navigation and 3D-printed modeling: illustrative case. Journal of Neurosurgery: Case Lessons 2021; 1:CASE2023. [PMID: 36045932 PMCID: PMC9394173 DOI: 10.3171/case2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/11/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cervicothoracic junction chordomas are uncommon primary spinal tumors optimally treated with en bloc resection. Although en bloc resection is the gold standard for treatment of mobile spinal chordoma, tumor location, size, and extent of involvement frequently complicate the achievement of negative margins. In particular, chordoma involving the thoracic region can require a challenging anterior access, and en bloc resection can lead to a highly destabilized spine. OBSERVATIONS Modern technological advances make en bloc resection more technically feasible than ever before. In this case, the successful en bloc resection of a particularly complex cervicothoracic junction chordoma was facilitated by a multidisciplinary surgical approach that maximized the use of intraoperative computed tomography–guided spinal navigation and patient-specific three-dimensional–printed modeling. LESSONS The authors review the surgical planning and specific techniques that facilitated the successful en bloc resection of this right-sided chordoma via image-guided parasagittal osteotomy across 2 stages. The integration of emerging visualization technologies into complex spinal column tumor management may help to provide optimal oncological care for patients with challenging primary tumors of the mobile spine.
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Affiliation(s)
- Nathan J. Pertsch
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
| | - Owen P. Leary
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
- Departments of Neurosurgery,
| | - Joaquin Q. Camara-Quintana
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
- Departments of Neurosurgery,
| | - David D. Liu
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
| | - Tianyi Niu
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
- Departments of Neurosurgery,
| | - Albert S. Woo
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
- Plastic Surgery, and
| | - Thomas T. Ng
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
- Thoracic Surgery, Rhode Island Hospital, Providence, Rhode Island
| | - Adetokunbo A. Oyelese
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
- Departments of Neurosurgery,
| | - Jared S. Fridley
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
- Departments of Neurosurgery,
| | - Ziya L. Gokaslan
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
- Departments of Neurosurgery,
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15
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Garcia CM, Pertsch NJ, Leary OP, Rivera Perla KM, Tang O, Toms SA, Weil RJ. Early outcomes of supratentorial cranial surgery for tumor resection in older patients. J Clin Neurosci 2020; 83:88-95. [PMID: 33342625 DOI: 10.1016/j.jocn.2020.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 09/15/2020] [Accepted: 11/23/2020] [Indexed: 01/12/2023]
Abstract
With longevity increasing in the United States, more older individuals are presenting with supratentorial brain tumors. Despite improved perioperative management, there is persistent disparity in surgical resection rates among patients aged 65 years or older. We aim to assess the effects of advanced age (≥65 years) on 30-day outcomes in patients with supratentorial tumors who underwent craniotomy for supratentorial tumor resection. Data obtained in adults who underwent supratentorial tumor resections was extracted from the prospectively-collected American College of Surgeons: National Surgical Quality Improvement Program (NSQIP; 2012-2018) database. Using multivariate regression, we compared odds of major and minor complications; prolonged length-of-stay (LOS); discharge anywhere other than home; and 30-day readmission, reoperation, and mortality rates between patients aged 18-64 years (the control cohort) and those 65-74 years or ≥75 years of age. Of the 14,234 patients who underwent craniotomy for supratentorial tumors and met inclusion criteria, 30.7% were ≥65 years of age; 71.4% of these were 65-74 years and 28.6% were ≥75 years old. Compared to the control group, both older subpopulations had more medical comorbidities. Both older subgroups had increased odds of major complications and prolonged LOS relative to the control group. Older patients had greater odds of mortality at 30 days. Advanced age, defined as ≥65 years, was significantly associated with higher odds of complications, prolonged LOS, and mortality within the 30-day post- operative period after adjusting for potential confounders. Age is one important consideration when prospectively risk-stratifying patients to minimize and mitigate suboptimal perioperative outcomes.
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Affiliation(s)
- Catherine M Garcia
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
| | - Nathan J Pertsch
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Owen P Leary
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | - Oliver Tang
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Steven A Toms
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
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16
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Sastry R, Pertsch NJ, Tang OY, Shao B, Toms SA, Weil RJ. Frailty and Outcomes After Craniotomy for Nontraumatic Subdural Hematoma. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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17
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Sastry RA, Pertsch NJ, Tang O, Shao B, Toms SA, Weil RJ. Frailty and outcomes after craniotomy for brain tumor. J Clin Neurosci 2020; 81:95-100. [PMID: 33222979 DOI: 10.1016/j.jocn.2020.09.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 09/06/2020] [Indexed: 12/22/2022]
Abstract
Frailty has been associated with increased morbidity and mortality in a variety of surgical disciplines. Few data exist regarding the relationship of frailty with adverse outcomes in craniotomy for brain tumor resection. We assessed the relationship between frailty and the incidence of major post-operative complication, discharge destination other than home, 30-day readmission, and 30-day mortality after elective craniotomy for brain tumor resection. A retrospective cohort study was conducted on 20,333 adult patients undergoing elective craniotomy for tumor resection in the 2012-2018 ACS-NSQIP Participant Use File. Multivariate logistic regression was performed using all covariates deemed eligible through clinical and statistical significance. 6,249 patients (30.7%) were low-frailty and 2,148 patients (10.6%) were medium-to-high frailty. In multivariate logistic regression adjusting for age, gender, BMI, ASA classification, smoking status, dyspnea, significant pre-operative weight loss, chronic steroid use, bleeding disorder, tumor type, and operative time, low frailty was associated with increased adjusted odds ratio of major complication (1.41, 95% CI: 1.23-1.60, p < 0.001), discharge destination other than home (1.32, 95% CI: 1.20-1.46, p < 0.001), 30-day readmission (1.29, 95% CI: 1.15-1.44, p < 0.001), and 30-day mortality (1.87, 95% CI: 1.41-2.47, p < 0.001). Moderate-to-high frailty was also associated with increased adjusted odds of major complication (1.61, 95% CI: 1.35-1.92, p < 0.001), discharge destination other than home (1.80, 95% CI: 1.58-2.05), 30-day readmission (1.39, 95% CI: 1.19-1.62, p < 0.001), and 30-day mortality (2.42, 95% CI: 1.74-3.38, p < 0.001). CONCLUSIONS: Frailty is associated with increased odds of major post-operative complication, discharge to destination other than home, 30-day readmission, and 30-day mortality.
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Affiliation(s)
- Rahul A Sastry
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, USA.
| | - Nathan J Pertsch
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, USA
| | - Oliver Tang
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, USA
| | - Belinda Shao
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, USA
| | - Steven A Toms
- Department of Neurosurgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02903, USA
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Lifespan Health System, Providence, RI 02903, USA
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18
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Leary OP, Crozier J, Liu DD, Niu T, Pertsch NJ, Camara-Quintana JQ, Svokos KA, Syed S, Telfeian AE, Oyelese AA, Woo AS, Gokaslan ZL, Fridley JS. Three-Dimensional Printed Anatomic Modeling for Surgical Planning and Real-Time Operative Guidance in Complex Primary Spinal Column Tumors: Single-Center Experience and Case Series. World Neurosurg 2020; 145:e116-e126. [PMID: 33010507 DOI: 10.1016/j.wneu.2020.09.145] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/24/2020] [Accepted: 09/25/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Three-dimensional (3D) printing has emerged as a visualization tool for clinicians and patients. We sought to use patient-specific 3D-printed anatomic modeling for preoperative planning and live intraoperative guidance in a series of complex primary spine tumors. METHODS Over 9 months, patients referred to a single neurosurgical provider for complex primary spinal column tumors were included. Most recent spinal magnetic resonance and computed tomography (CT) imaging were semiautomatically segmented for relevant anatomy and models were printed using polyjet multicolor printing technology. Models were available to surgical teams before and during the operative procedure. Patients also viewed the models preoperatively during surgeon explanation of disease and surgical plan to aid in their understanding. RESULTS Tumor models were prepared for 9 patients, including 4 with chordomas, 2 with schwannomas, 1 with osteosarcoma, 1 with chondrosarcoma, and 1 with Ewing-like sarcoma. Mean age was 50.7 years (range, 15-82 years), including 6 males and 3 females. Mean tumor volume was 129.6 cm3 (range, 3.3-250.0 cm3). Lesions were located at cervical, thoracic, and sacral levels and were treated by various surgical approaches. Models were intraoperatively used as patient-specific anatomic references throughout 7 cases and were found to be technically useful by the surgical teams. CONCLUSIONS We present the largest case series of 3D-printed spine tumor models reported to date. 3D-printed models are broadly useful for operative planning and intraoperative guidance in spinal oncology surgery.
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Affiliation(s)
- Owen P Leary
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
| | - Joseph Crozier
- Department of Plastic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - David D Liu
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Tianyi Niu
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Nathan J Pertsch
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Joaquin Q Camara-Quintana
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Konstantina A Svokos
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Sohail Syed
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Albert E Telfeian
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Albert S Woo
- Department of Plastic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Jared S Fridley
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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19
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Pertsch NJ, Tang OY, Seicean A, Toms SA, Weil RJ. Sepsis after elective neurosurgery: Incidence, outcomes, and predictive factors. J Clin Neurosci 2020; 78:53-59. [PMID: 32624367 DOI: 10.1016/j.jocn.2020.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/18/2020] [Indexed: 11/25/2022]
Abstract
Sepsis is a life-threatening condition resulting from systemic infection, with mortality rates approaching 30%. Most neurological surgeries are now performed electively, which permits medical optimization preoperatively. We performed a retrospective cohort analysis of 122,466 adult elective neurosurgical patients from 2012 to 2018 in the National Surgical Quality Improvement Program database. To select for a medically optimized population, patients were included if they arrived from home on the day of surgery, were not pregnant or puerperium, and had no documented evidence of preexisting infection. We analyzed demographic, comorbidity, and operative information; performed multivariate logistic regression to explore factors predictive of postoperative sepsis; and evaluated outcomes for patients who developed sepsis. Overall, 0.87% of patients developed postoperative sepsis (n = 1,067). The rate of sepsis was higher in the cranial subpopulation (1.21%; n = 330) and lower in the spinal subpopulation (0.77%; n = 733). The overall sepsis cohort was older, had more males, was more functionally dependent, had longer operation durations, and had higher rates of medical comorbidities. Minority race and smoking were not associated with sepsis. The sepsis cohort fared worse than the control cohort across all outcome measures, including prolonged length-of-stay (≥90th percentile), discharge anywhere but home, 30-day readmission, 30-day reoperation, and 30-day mortality. Results for the cranial and spine subpopulations follow similar trends. In summary, sepsis in the elective neurosurgical population is an uncommon but devastating cause of excess morbidity and mortality.
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Affiliation(s)
- Nathan J Pertsch
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States.
| | - Oliver Y Tang
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
| | - Andreea Seicean
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL, United States
| | - Steven A Toms
- The Warren Alpert School of Medicine, Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
| | - Robert J Weil
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
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20
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Lamas DJ, Owens RL, Nace RN, Massaro AF, Pertsch NJ, Moore ST, Bernacki RE, Block SD. Conversations About Goals and Values Are Feasible and Acceptable in Long-Term Acute Care Hospitals: A Pilot Study. J Palliat Med 2017; 20:710-715. [DOI: 10.1089/jpm.2016.0485] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Daniela J. Lamas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Ariadne Labs at Brigham and Women's Hospital and Harvard T.H. Chen School of Public Health, Boston, Massachusetts
| | - Robert L. Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, California
| | - R. Nicholas Nace
- Department of Medicine, Spaulding Hospital for Continuing Medical Care, Cambridge, Massachusetts
| | - Anthony F. Massaro
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nathan J. Pertsch
- Ariadne Labs at Brigham and Women's Hospital and Harvard T.H. Chen School of Public Health, Boston, Massachusetts
| | - Susan T. Moore
- Department of Medicine, Spaulding Hospital for Continuing Medical Care, Cambridge, Massachusetts
| | - Rachelle E. Bernacki
- Ariadne Labs at Brigham and Women's Hospital and Harvard T.H. Chen School of Public Health, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan D. Block
- Ariadne Labs at Brigham and Women's Hospital and Harvard T.H. Chen School of Public Health, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
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