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A significant portion of health care spending is driven by a small percentage of the overall population. Understanding risk factors predisposing patients to disproportionate use of health care resources is critical. Our objective was to identify risk factors leading to a prolonged length of stay (LOS) after cervical spine surgery.A single-center cohort analysis was performed on patients who underwent elective anterior spine surgery from 2015 to 2021. Multivariate logistic regression evaluated the effects of sociodemographic factors including Area of Deprivation Index (quantifies income, education, employment, and housing quality), procedural, and discharge characteristics on postoperative LOS. Extended LOS was defined as greater than the 90th percentile in midnights for the study population (≥3 midnights).A total of 686 patients were included in the study, with a mean age of 57 years (range, 26-92 years), median of 1 level (1-4) fused, and median LOS of 1 midnight (interquartile range, 1-2). After adjusting for confounders, patients had increased odds of extended LOS if they were highly disadvantaged on the Area of Deprivation Index (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.04-4.82; P = 0.039); had surgery on Thursday or Friday (OR, 1.94; 95% CI, 1.01-3.72; P = 0.046); had a corpectomy performed (OR, 2.81; 95% CI, 1.26-6.28; P = 0.012); or discharged not to home (OR, 8.24; 95% CI, 2.88-23.56; P 0.001). Patients with extended LOS were more likely to present to the emergency department or be readmitted within 30 days after discharge (P = 0.024).After adjusting for potential cofounders, patients most disadvantaged on Area of Deprivation Index were more likely to have an extended LOS.

The National Inpatient Sample (NIS) (the largest all-payer inpatient database in the United States) is an important instrument for big data analysis of neurosurgical inquiries. However, earlier research has determined that many NIS studies are limited by common methodological pitfalls. In this study, we provide the first primer of NIS methodological procedures in the setting of neurosurgical research and review all reported neurosurgical studies using the NIS.We designed a protocol for neurosurgical big data research using the NIS, based on our subject matter expertise, NIS documentation, and input and verification from the Healthcare Cost and Utilization Project. We subsequently used a comprehensive search strategy to identify all neurosurgical studies using the NIS in the PubMed and MEDLINE, Embase, and Web of Science databases from inception to August 2021. Studies underwent qualitative categorization (years of NIS studied, neurosurgical subspecialty, age group, and thematic focus of study objective) and analysis of longitudinal trends.We identified a canonical, 4-step protocol for NIS analysis: study population selection; defining additional clinical variables; identification and coding of outcomes; and statistical analysis. Methodological nuances discussed include identifying neurosurgery-specific admissions, addressing missing data, calculating additional severity and hospital-specific metrics, coding perioperative complications, and applying survey weights to make nationwide estimates. Inherent database limitations and common pitfalls of NIS studies discussed include lack of disease process-specific variables and data after the index admission, inability to calculate certain hospital-specific variables after 2011, performing state-level analyses, conflating hospitalization charges and costs, and not following proper statistical methodology for performing survey-weighted regression. In a systematic review, we identified 647 neurosurgical studies using the NIS. Although almost 60% of studies were reported after 2015,10% of studies analyzed NIS data after 2015. The average sample size of studies was 507,352 patients (standard deviation = 2,739,900). Most studies analyzed cranial procedures (58.1%) and adults (68.1%). The most prevalent topic areas analyzed were surgical outcome trends (35.7%) and health policy and economics (17.8%), whereas patient disparities (9.4%) and surgeon or hospital volume (6.6%) were the least studied.We present a standardized methodology to analyze the NIS, systematically review the state of the NIS neurosurgical literature, suggest potential future directions for neurosurgical big data inquiries, and outline recommendations to improve the design of future neurosurgical data instruments.

Encouraging early time of discharge (TOD) for medical inpatients is commonplace and may potentially improve patient throughput. It is unclear, however, whether early TOD after elective spine surgery achieves this goal without a consequent increase in re-presentations to the hospital.To evaluate whether early TOD results in increased rates of hospital readmission or return to the emergency department after elective anterior cervical spine surgery.We analyzed 686 patients who underwent elective uncomplicated anterior cervical spine surgery at a single institution. Logistic regression was used to evaluate the relationship between sociodemographic, procedural, and discharge characteristics, and the outcomes of readmission or return to the emergency department and TOD.In multiple logistic regression, TOD was not associated with increased risk of readmission or return to the emergency department within 30 days of surgery. Weekend discharge (odds ratio [OR] 0.33, 95% CI 0.21-0.53), physical therapy evaluation (OR 0.44, 95% CI 0.28-0.71), and occupational therapy evaluation (OR 0.32, 95% CI 0.17-0.63) were all significantly associated with decreased odds of discharge before noon. Disadvantaged status, as measured by area of deprivation index, was associated with increased odds of readmission or re-presentation (OR 1.86, 95% CI 0.95-3.66), although this result did not achieve statistical significance.There does not appear to be an association between readmission or return to the emergency department and early TOD after elective spine surgery. Overuse of inpatient physical and occupational therapy consultations may contribute to decreased patient throughput in surgical admissions.

Data Spreadsheet from Protein Profiling in Brain Tumors Using Mass Spectrometry

Legend from Protein Profiling in Brain Tumors Using Mass Spectrometry

PDF file - 695K, Significantly increased mRNA Expression of TNF-R1 and TNF-R2 in GBM as compared to normal brain

PDF file - 223K, Aptamer high tumor cells display preferential invasion.

PDF file - 658K, Characterization of the integrin receptors mediating the attachment of primary brain ECs to collagen, fibronectin and laminin.

PDF file - 481K, Dose-dependent TNF�\�{induced apoptosis of primary brain ECs.

PDF file - 1MB, Absence of cFLIP expression in human GBM cells and human GBM stem cells plated on laminin

Retrospective studies of breast cancer patients suggest that primary tumor Her-2 overexpression or trastuzumab therapy is associated with a devastating complication: the development of central nervous system (brain) metastases. Herein, we present Her-2 expression trends from resected human brain metastases and data from an experimental brain metastasis assay, both indicative of a functional contribution of Her-2 to brain metastatic colonization. Of 124 archival resected brain metastases from breast cancer patients, 36.2% overexpressed Her-2, indicating an enrichment in the frequency of tumor Her-2 overexpression at this metastatic site. Using quantitative real-time PCR of laser capture microdissected epithelial cells, Her-2 and epidermal growth factor receptor (EGFR) mRNA levels in a cohort of 12 frozen brain metastases were increased up to 5- and 9-fold, respectively, over those of Her-2–amplified primary tumors. Co-overexpression of Her-2 and EGFR was also observed in a subset of brain metastases. We then tested the hypothesis that overexpression of Her-2 increases the colonization of breast cancer cells in the brain in vivo. A subclone of MDA-MB-231 human breast carcinoma cells that selectively metastasizes to brain (231-BR) overexpressed EGFR; 231-BR cells were transfected with low (4- to 8-fold) or high (22- to 28-fold) levels of Her-2. In vivo, in a model of brain metastasis, low or high Her-2–overexpressing 231-BR clones produced comparable numbers of micrometastases in the brain as control transfectants; however, the Her-2 transfectants yielded 3-fold greater large metastases (>50 μm2; P < 0.001). Our data indicate that Her-2 overexpression increases the outgrowth of metastatic tumor cells in the brain in this model system. [Cancer Res 2007;67(9):4190–8]

PDF file - 61K

PDF file - 42K, Aptamer Sequences.

PDF file - 72K, Increased Expression of TNFalpha, TNF-R1 and TNF-R2 in the ECs in Recurrent GBM

PDF file - 972K, Percent of ECs expressing integrin alpha 6 beta 1 versus integrin alpha 6 beta 4.

Supplementary Table 1 from Her-2 Overexpression Increases the Metastatic Outgrowth of Breast Cancer Cells in the Brain

PDF file - 279K, Aptamer A4 high cells have a differential genetic profile associated with downregulation of genes involved in cellular development.

PDF file - 87K, TIC-specific aptamers preferentially bind TICs in comparison to non-TICs or U87MG cells.

Supplementary Table 2 from Her-2 Overexpression Increases the Metastatic Outgrowth of Breast Cancer Cells in the Brain

PDF file - 71K, Increased Expression of TNFalpha, TNF-R1 and TNF-R2 in the ECs in Untreated GBM

PDF file - 86K, TIC- specific aptamers display specificity for TICs.

PDF file - 226K, TIC-specific apatmers internalize specifically into TICs.

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.

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.

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

Background Frailty is associated with adverse outcomes in traumatically injured geriatric patients but has not been well-studied in geriatric Traumatic Brain Injury (TBI). Objective To assess relationships between frailty and outcomes after TBI Methods The records of all patients aged 70 or older admitted from home to the neurosurgical service of a single institution for non-operative TBI between January 2020 and July 2021 were retrospectively reviewed. The primary outcome was adverse discharge disposition (either in-hospital expiration or discharge to skilled nursing facility (SNF), hospice, or home with hospice). Secondary outcomes included major inpatient complication, 30-day readmission, and length of stay. Results 100 patients were included, 90% of whom presented with Glasgow Coma Score (GCS) 14–15. The mean length of stay was 3.78 days. 7% had an in-hospital complication, and 44% had an unfavorable discharge destination. 49% of patients attended follow-up within 3 months. The rate of readmission within 30 days was 13%. Patients were characterized as low frailty (FRAIL score 0–1, n = 35, 35%) or high frailty (FRAIL score 2–5, n = 65, 65%). In multivariate analysis controlling for age and other factors, frailty category (aOR 2.63, 95CI [1.02, 7.14], p = 0.005) was significantly associated with unfavorable discharge. Frailty was not associated with increased readmission rate, LOS, or rate of complications on uncontrolled univariate analyses. Conclusion Frailty is associated with increased odds of unfavorable discharge disposition for geriatric patients admitted with TBI.

In the context of increased attention afforded to hospital efficiency and improved but safe patient throughput, decreasing unnecessary hospital length of stay (LOS) is imperative. Given that lumbar spine procedures may be among a hospital's most profitable services, identifying patients at risk of increased healthcare resource utilization prior to surgery is a valuable opportunity to develop targeted pre- and peri-operative intervention and quality improvement initiatives. The purpose of the present investigation was to examine patient factors that predict prolonged LOS as well as discharge disposition following elective, posterior, lumbar spine surgery.We employed a retrospective cohort analysis on 779 consecutive patients treated with lumbar surgery without fusion. Our primary outcome measures were extended LOS (three or more midnights) and discharge disposition. Patient sociodemographic, procedural, and discharge characteristics were adjusted for in our analysis. Sociodemographic variables included Area of Deprivation Index (ADI), a comprehensive metric of socioeconomic status, utilizing income, education, employment, and housing quality based on patient zip code. Multivariable logistic regression and ordinal logistic regression analyses were performed to assess whether covariates were independently predictive of extended LOS and discharge disposition, respectively.779 patients were studied, with a median age of 66 years (±15) and a median LOS of 1 midnight (range, 1-10 midnights). Patients in the most disadvantaged ADI quintile (adjusted odds ratio, aOR 2.48 95% CI 1.15-5.47), those who underwent a minimally-invasive or tubular retractor surgery (aOR 3.03 95% CI 1.02-8.56), those who had an intra-operative drain placed (aOR 4.46 95% CI 2.53-7.26), who had a cerebrospinal fluid leak (aOR 3.46 95% CI 1.55-7.58), who were discharged anywhere but home (aOR 17.11 95% CI 9.24-33.00), and those who were evaluated by physical therapy (aOR 7.23 95% CI 2.13-45.30) or OT (aOR 2.20 95% CI 1.13-4.22) had a significantly increased chance of an extended LOS. Preoperative opioid use was not associated with an increased LOS following surgery (aOR 1.12 95% CI 0.56-1.46). Extended LOS was not associated with post-discharge emergency department representation or unplanned readmission within 90 days following discharge (p=0.148). Patients who were older (aOR 1.99 95% CI 1.62-2.48), in higher quintiles on ADI (3rd quintile; aOR 1.90 95% CI 1.12-3.23, 4th quintile; aOR 1.79, 95% CI 1.05-3.05, 5th quintile; aOR 2.16 95% CI 1.26-3.75), who had a CSF leak (aOR 2.18 95% CI 1.22-3.86), or who had a longer procedure duration (aOR 1.38 95% CI 1.17-1.62) were more likely to require additional services or be sent to a subacute facility upon discharge.Patient sociodemographics, along with procedural factors, and discharge disposition were all associated with an increased likelihood of prolonged LOS and resource intensive discharges following elective lumbar spine surgery. Several of these factors could be reliably identified pre-operatively and may be amenable to targeted preoperative intervention. Improving discharge disposition planning in the peri-operative period may allow for more efficient use of hospitalization and inpatient and post-acute resources.

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.

Objective Frailty is a measure of decreased physiologic reserve and has been associated with increased morbidity and mortality in a variety of surgical disciplines. No data exist regarding the relationship of frailty with adverse outcomes in craniotomy for chronic subdural evacuation. We assessed the relationship between frailty and the incidence of major postoperative complication, discharge destination other than home, 30-day readmission, and 30-day mortality after craniotomy for atraumatic subdural evacuation. Methods A retrospective cohort study was conducted on a population of 1647 adult patients undergoing craniotomy for evacuation of atraumatic subdural hematoma in the 2005–2018 American College of Surgeons National Surgical Quality Improvement Program database. Frailty was assessed using the modified frailty index (mFI-5). Multivariable logistic regression was performed using all covariates deemed eligible through clinical relevance and statistical significance. Results The overall rates of major complication (25.4%), discharge to destination other than home (49.8%), 30-day readmission (11.7%), and 30-day mortality (12.8%) in this analysis were high and rose with increasing frailty. In multivariable regression analyses, medium frailty (mFI-5 = 2) was associated with increased odds of major complication (adjusted odds ratio [aOR] 1.64, 95% confidence interval [CI] 1.03–2.63), discharge to destination other than home (aOR 2.04, 95% CI 1.38–3.02), and 30-day mortality (aOR 2.27, 95% CI 1.08–4.78). High frailty (mFI-5 >2) was associated with increased odds of 30-day mortality (aOR 2.85, 95% CI 1.13–7.14). Conclusions Preoperative frailty, as determined by mFI-5, is associated with increased odds of major postoperative complication, discharge to destination other than home, and 30-day mortality after craniotomy for chronic subdural hematoma.

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.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.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; P0.001), 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; P0.001), 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.Metabolic syndrome is associated with adverse outcomes for adult patients undergoing elective CEA.

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.

Background Compared to normal cells, cancer cells exhibit a higher level of oxidative stress, which primes key cellular and metabolic pathways and thereby increases their resilience under oxidative stress. This higher level of oxidative stress also can be exploited to kill tumor cells while leaving normal cells intact. In this study we have found that isovalerylspiramycin I (ISP I), a novel macrolide antibiotic, suppresses cancer cell growth and tumor metastases by targeting the nucleolar protein selenoprotein H (SELH), which plays critical roles in keeping redox homeostasis and genome stability in cancer cells. Methods We developed ISP I through genetic recombination and tested the antitumor effects using primary and metastatic cancer models. The drug target was identified using the drug affinity responsive target stability (DARTS) and mass spectrum assays. The effects of ISP I were assessed for reactive oxygen species (ROS) generation, DNA damage, R-loop formation and its impact on the JNK2/TIF-IA/RNA polymerase I (POLI) transcription pathway. Results ISP I suppresses cancer cell growth and tumor metastases by targeting SELH. Suppression of SELH induces accumulation of ROS and cancer cell-specific genomic instability. The accumulation of ROS in the nucleolus triggers nucleolar stress and blocks ribosomal RNA transcription via the JNK2/TIF-IA/POLI pathway, causing cell cycle arrest and apoptosis in cancer cells. Conclusions We demonstrated that ISP I links cancer cell vulnerability to oxidative stress and RNA biogenesis by targeting SELH. This suggests a potential new cancer treatment paradigm, in which the primary therapeutic agent has minimal side-effects and hence may be useful for long-term cancer chemoprevention.

Dual-eligible (DE) patients, simultaneous Medicare and Medicaid beneficiaries, have been shown to have poorer clinical outcomes while incurring higher resource utilization. However, neurosurgical oncology outcomes for DE patients are poorly characterized. Accordingly, we examined the impact of DE status on perioperative outcomes following glioma, meningioma, or metastasis resection.We identified all admissions undergoing a craniotomy for glioma, meningioma, or metastasis resection in the National Inpatient Sample from 2002 to 2011. Assessed outcomes included inpatient mortality, complications, discharge disposition, length of stay (LOS), and hospital costs. Multivariable regression adjusting for 13 patient, severity, and hospital characteristics assessed the association between DE status and outcomes, relative to four reference insurance groups (Medicare-only, Medicaid-only, private insurance, self-pay).Of 195,725 total admissions analyzed, 3.0% were dual-eligible beneficiaries (n = 5933). DEs were younger than Medicare admissions (P 0.001) but older than Medicaid, private, and self-pay admissions (P 0.001). Relative to other insurance groups, DEs also exhibited higher severity of illness, risk of mortality, and Charlson Comorbidity Index scores as well as treatment at low-volume hospitals (all P 0.001). DEs had lower mortality than self-pay admissions (odds ratio [OR] 0.47, P = 0.017). Compared to Medicare, Medicaid, private, and self-pay admissions, DEs had lower rates of discharge disposition (OR 0.53, 0.50, 0.34, and 0.27, respectively, all P 0.001). DEs also had higher complications (OR 1.23 and 1.20, respectively, both P 0.05) and LOS (β = 1.06 and 1.13, respectively, both P 0.01) than Medicare and private insurance beneficiaries. Differences in discharge disposition remained significant for all three tumor subtypes, but only glioma DE admissions continued to exhibit higher complications and LOS.DEs undergoing definitive craniotomy for brain tumor had higher rates of unfavorable discharge disposition compared to all other insurance groups and, especially for glioma surgery, had higher inpatient complication rates and LOS. Practice and policy reforms to improve outcomes for this vulnerable clinical population are warranted.

Socioeconomic factors, such as insurance status, have been shown to affect outcomes for patients following emergency injuries. Dual-eligible beneficiaries, receiving both Medicare and Medicaid, constitute an especially vulnerable population. There is limited data addressing whether dual-eligible beneficiaries with hemorrhagic stroke display unique characteristics and outcomes compared to patients with Medicare, Medicaid, or private insurance.We conducted a retrospective analysis of 10-years of National Inpatient Sample data. Using ICD-9-CM codes, we identified adult patients with known insurance status who were emergently hospitalized for intracranial hemorrhage; epidural, subdural, subarachnoid, and intracerebral hemorrhages were included. Patient characteristics including whether they underwent surgical intervention were collected. Multivariable logistic regression was used to adjust for confounders. Primary clinical outcomes of interest included mortality (in-hospital), complications (any), and favorable discharge (home/home with services).Among 410,621 patients, dual-eligible (6.8%) patients were on average older (mean age = 73yrs) compared to Medicaid (46yrs), private insurance (67yrs), or no-charge (47yrs) patients. Caucasian race was highest among Medicare patients (83%) while African-American race was highest among Medicaid (22%). Among all patients, 5.3% underwent operative intervention. Dual-eligibles had significantly higher odds of in-hospital mortality compared to no-charge (adjusted odds ratio (aOR) = 1.61, 95% CI = [1.04 - 2.49]), but no significant difference between Medicare and Medicaid although dual-eligibles. Dual-eligibles had significantly increased odds of complications compared to Medicaid (aOR = 1.23, 95% CI = [1.11 - 1.37]) and privately insured patients (aOR = 1.19, 95% CI = [1.11 - 1.28]), both p 0.001, and lower odds of favorable discharge compared to all other groups, all p 0.001. Dual-eligibles underwent a shorter length of stay, an 18% decrease, compared to Medicaid patients (β-Coefficient = 0.82, 95% CI = [0.78 - 0.86], p 0.001), and inflation adjusted admission costs that were 24% lower compared to Medicaid patients (β-Coefficient = 0.76, 95% CI = [0.73 - 0.80], p 0.001), amounting to a $3,684 decrease in cost.Dual-eligible beneficiaries experience unique health disparities from lower odds of favorable discharge to increased odds of complications and in-hospital mortality compared to other insured and uninsured groups. Adverse outcomes among dual-eligible beneficiaries highlight the need to uncover and address unknown sources of disparities to improve emergency treatment of hemorrhagic stroke in this population.

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

OBJECTIVEThe goal of this study was to compare outcomes of carotid endarterectomy performed by neurological, general, and vascular surgeons.METHODSThe authors identified 80,475 patients who underwent carotid endarterectomy between 2006 and 2015 in the National Surgical Quality Improvement Program, a prospectively collected, national clinical database with established reproducibility and validity. Nine hundred forty-three patients were operated on by a neurosurgeon; 75,649 by a vascular surgeon; and 3734 by a general surgeon. Preoperative and intraoperative characteristics and 30-day outcomes were stratified by the surgeon’s primary specialty. Using propensity scores, comprising pre- and intraoperative characteristics as well as procedure and diagnostic codes, the authors matched 203 neurosurgery (NS) patients to 203 vascular surgery (VS) patients and 203 NS patients to 203 general surgery (GS) patients. No pre- or intraoperative factors were significantly different between specialties in the matched sample. Regular logistic regression and conditional logistic regression were used to predict postoperative complications in the full sample and in the matched sample.RESULTSIn the complete population sample, NS patients, when compared to patients of general and vascular surgeons, were less likely to be admitted from home and more likely to have carotid artery occlusion or stenosis with cerebral infarction, to be a current smoker, to have had recent chemo- or radiotherapy, to have surgery under general anesthesia, to undergo multiple procedures, and to have longer surgery times. In unadjusted analyses, NS patients were more likely to experience major complications (NS vs VS: odds ratio 1.3, 95% CI 1.1–1.6; NS vs GS: odds ratio 1.3, 95% CI 1.0–1.7); minor complications (NS vs VS: odds ratio 2.9, 95% CI 2.0–4.1; NS vs GS: odds ratio 2.7, 95% CI 1.7–4.2); intra- or postoperative transfusions (NS vs VS: odds ratio 1.6, 95% CI 1.4–1.9; NS vs GS: odds ratio 1.9, 95% CI 1.6–2.3); prolonged hospitalization (NS vs VS: odds ratio 3.0, 95% CI 2.6–3.5; NS vs GS: odds ratio 2.6, 95% CI 2.2–3.0); and discharge to skilled care facilities (NS vs VS: odds ratio 2.8, 95% CI 2.3–3.4; NS vs GS: odds ratio 3.1, 95% CI 2.4–4.1). In adjusted, propensity-matched analyses, however, patients’ outcome with carotid endarterectomy performed by NS was comparable with those completed by GS and VS.CONCLUSIONSPatients who undergo carotid endarterectomy performed by a neurosurgeon tend to have a greater preoperative disease burden than do those treated by a general or vascular surgeon, which contributes significantly to more morbid postoperative courses. In patients matched carefully on the basis of health status at the time of surgery and intraoperative variables that affect results, patients’ outcomes after carotid endarterectomy do not appear to depend on the attending surgeon’s primary specialty.

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

Background Outcome disparities have been documented at safety-net hospitals (SNHs), which disproportionately serve vulnerable patient populations. Using a nationwide retrospective cohort, we assessed inpatient outcomes following brain tumor craniotomy at SNHs in the United States. Methods We identified all craniotomy procedures in the National Inpatient Sample from 2002–2011 for brain tumors: glioma, metastasis, meningioma, and vestibular schwannoma. Safety-net burden was calculated as the number of Medicaid plus uninsured admissions divided by total admissions. Hospitals in the top quartile of burden were defined as SNHs. The association between SNH status and in-hospital mortality, discharge disposition, complications, hospital-acquired conditions (HACs), length of stay (LOS), and costs were assessed. Multivariate regression adjusted for patient, hospital, and severity characteristics. Results 304,719 admissions were analyzed. The most common subtype was glioma (43.8%). Of 1,206 unique hospitals, 242 were SNHs. SNH admissions were more likely to be non-white (P < .001), low income (P < .001), and have higher severity scores (P = .034). Mortality rates were higher at SNHs for metastasis admissions (odds ratio [OR] = 1.48, P = .025), and SNHs had higher complication rates for meningioma (OR = 1.34, P = .003) and all tumor types combined (OR = 1.17, P = .034). However, there were no differences at SNHs for discharge disposition or HACs. LOS and hospital costs were elevated at SNHs for all subtypes, culminating in a 10% and 9% increase in LOS and costs for the overall population, respectively (all P < .001). Conclusions SNHs demonstrated poorer inpatient outcomes for brain tumor craniotomy. Further analyses of the differences observed and potential interventions to ameliorate interhospital disparities are warranted.

Dual-eligible beneficiaries, individuals with both Medicare and Medicaid coverage, represent a high-cost and vulnerable population; however, literature regarding outcomes is sparse. We characterized outcomes in dual-eligible beneficiaries treated for aneurysmal subarachnoid hemorrhage (aSAH) compared to Medicare only, Medicaid only, private insurance, and self-pay. A 10-year cross-sectional study of the National Inpatient Sample was conducted. Adult aSAH emergency admissions treated by neurosurgical clipping or endovascular coiling were included. Multivariable regression was used to adjust for confounders. A total of 57,666 patients met inclusion criteria. Dual-eligibles comprised 2.8% of admissions and were on average younger (62.4 years) than Medicare (70.0 years), older than all other groups, and had higher mean National Inpatient Sample-Subarachnoid Hemorrhage Severity Scores than all other groups (p ≤ 0.001). Among patients treated by clipping, dual-eligibles were less often discharged to home compared to Medicare (adjusted odds ratio (aOR) = 0.51, 95% CI = 0.30-0.87, p

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.

Background To examine the clinical and hormonal profiles, comorbidities, treatment patterns, surgical pathology and clinical outcomes of patients diagnosed with acromegaly at the Cleveland Clinic over a 15-year period. Methods A retrospective chart review of patients with acromegaly who underwent surgical resection between 2003 and 2018. Results A total of 136 patients (62 men; mean age 48.1 years) with biochemical evidence of acromegaly were analyzed. Median insulin-like growth factor 1 (IGF-1) level at diagnosis was 769.0 ng/mL and most patients had a macroadenoma (82.2%). Immunoreactivity to growth hormone (GH) was noted in 124 adenomas, with co-staining in 89 adenomas. Complete visible tumor resection during initial surgery was achieved in 87 patients (64.0%). In this cohort, complete response to surgery alone was observed in 61 patients (70.1%), while 31 out of 65 patients (47.7%) who received additional post-surgical medications and/or radiation therapy achieved complete response. At most recent follow-up, 92 patients achieved eventual complete response by documented normalization of IGF-1 levels. Higher IGF-1 level at diagnosis (P = 0.024) and cavernous sinus invasion (P = 0.028) were predictors for failure to respond to surgery. Conclusion In this study, the majority of tumors were macroadenoma, plurihormonal, and treated effectively with surgery alone or surgery with adjuvant medical or radiation therapy. More studies are needed to identify additional molecular biomarkers, tumor characteristics and imaging findings to individualize treatment and better predict treatment outcomes.

Context Inferior petrosal sinus sampling (IPSS) helps differentiate the source of ACTH-dependent hypercortisolism in patients with inconclusive biochemical testing and imaging, and is considered the gold standard for distinguishing Cushing disease (CD) from ectopic ACTH syndrome. We present a comprehensive approach to interpreting IPSS results by examining several real cases. Evidence Acquisition We performed a comprehensive review of the IPSS literature using PubMed since IPSS was first described in 1977. Evidence Synthesis IPSS cannot be used to confirm the diagnosis of ACTH-dependent Cushing syndrome (CS). It is essential to establish ACTH-dependent hypercortisolism before the procedure. IPSS must be performed by an experienced interventional or neuroradiologist because successful sinus cannulation relies on operator experience. In patients with suspected cyclical CS, it is important to demonstrate the presence of hypercortisolism before IPSS. Concurrent measurement of IPS prolactin levels is useful to confirm adequate IPS venous efflux. This is essential in patients who lack an IPS-to-peripheral (IPS:P) ACTH gradient, suggesting an ectopic source. The prolactin-adjusted IPS:P ACTH ratio can improve differentiation between CD and ectopic ACTH syndrome when there is a lack of proper IPS venous efflux. In patients who have unilateral successful IPS cannulation, a contralateral source cannot be excluded. The value of the intersinus ACTH ratio to predict tumor lateralization may be improved using a prolactin-adjusted ACTH ratio, but this requires further evaluation. Conclusion A stepwise approach in performing and interpreting IPSS will provide clinicians with the best information from this important but delicate procedure.

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.

Introduction: An individual classified as American Society of Anesthesiologists (ASA) physical status 5 (ASA 5) is described as “a moribund patient who is not expected to survive without the operation.” We examined the outcomes of ASA 5 patients who underwent an index neurosurgical operation to characterize surgical results and to identify risk factors for adverse outcomes in this population. Methods: We used the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to identify 689 ASA 5 patients who underwent neurological surgery at any one of the 706 institutions participating in the NSQIP between 2006 and 2016. We used univariate logistic regression to identify baseline factors associated with adverse post-operative outcomes; all factors identified were incorporated into the final multivariate models. Results: Of the entire study population of 689 patients, 90% (n = 620) had an emergency operation and 89% (n = 613) had a cranial procedure. At 30 days, 11% remained hospitalized, 5% had been readmitted to an acute care hospital, 16% required an additional, unplanned surgery, and 39% had expired. The most common post-operative complications were prolonged (>48 h) mechanical ventilation (57%), transfusion of blood or blood products (26%), and pneumonia (23%); for patients with these complications, the 30-day mortality rates were 61%, 33%, and 19%, respectively. The vast majority (81%) of those who survived to discharge required continued care at a location other than home.In multivariate models, a variety of medical, surgical and socioeconomic factors were identified that increased the risk of prolonged length of stay, peri- and post-operative transfusion of blood or blood products, unplanned return to the operating room, re-admission within 30 days, and continued care after discharge. Conclusions: While post-operative complications are common, >60% of ASA 5 patients who undergo neurosurgery survive and 20% are discharged home within 30 days. These novel findings may be useful to inform decision-making in critically-ill neurosurgical patients. Keywords: Surgery, Mortality, Length of stay, Complications, Risk factors, Health services research, Neurosurgery, Craniotomy, Re-admissions, Re-operation, Brain, Spine

OBJECTIVEResearch has documented significant growth in neurosurgical expenditures and practice consolidation. The authors evaluated the relationship between interhospital competition and inpatient charges or costs in patients undergoing cranial neurosurgery.METHODSThe authors identified all admissions in 2006 and 2009 from the National Inpatient Sample. Admissions were classified into 5 subspecialties: cerebrovascular, tumor, CSF diversion, neurotrauma, or functional. Hospital-specific interhospital competition levels were quantified using the Herfindahl-Hirschman Index (HHI), an economic metric ranging continuously from 0 (significant competition) to 1 (monopoly). Inpatient charges (hospital billing) were multiplied with reported cost-to-charge ratios to calculate costs (actual resource use). Multivariate regressions were used to assess the association between HHI and inpatient charges or costs separately, controlling for 17 patient, hospital, severity, and economic factors. The reported β-coefficients reflect percentage changes in charges or costs (e.g., β-coefficient = 1.06 denotes a +6% change). All results correspond to a standardized −0.1 change in HHI (increase in competition).RESULTSIn total, 472,938 nationwide admissions for cranial neurosurgery treated at 896 unique hospitals met inclusion criteria. Hospital HHIs ranged from 0.099 to 0.724 (mean 0.298 ± 0.105). Hospitals in more competitive markets had greater charge/cost markups (β-coefficient = 1.10, p < 0.001) and area wage indices (β-coefficient = 1.04, p < 0.001). Between 2006 and 2009, average neurosurgical charges and costs rose significantly ($62,098 to $77,812, p < 0.001; $21,385 to $22,389, p < 0.001, respectively). Increased interhospital competition was associated with greater charges for all admissions (β-coefficient = 1.07, p < 0.001) as well as cerebrovascular (β-coefficient = 1.08, p < 0.001), tumor (β-coefficient = 1.05, p = 0.039), CSF diversion (β-coefficient = 1.08, p < 0.001), neurotrauma (β-coefficient = 1.07, p < 0.001), and functional neurosurgery (β-coefficient = 1.11, p = 0.037) admissions. However, no significant associations were observed between HHI and costs, except for CSF diversion surgery (β-coefficient = 1.03, p = 0.021). Increased competition was not associated with important clinical outcomes, such as inpatient mortality, favorable discharge disposition, or complication rates, except for lower mortality for brain tumors (OR 0.78, p = 0.026), but was related to greater length of stay for all admissions (β-coefficient = 1.06, p < 0.001). For a sensitivity analysis adjusting for outcomes, all findings for charges and costs remained the same.CONCLUSIONSHospitals in more competitive markets exhibited higher charges for admissions of patients undergoing an in-hospital cranial procedure. Despite this, interhospital competition was not associated with increased inpatient costs except for CSF diversion surgery. There was no corresponding improvement in outcomes with increased competition, with the exception of a potential survival benefit for brain tumor surgery.