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Degenerative cervical myelopathy (DCM) is a poorly recognised form of spinal cord injury which arises when degenerative changes in the cervical spine injure the spinal cord. Timely surgical intervention is critical to preventing disability. Despite this, DCM is frequently undiagnosed, and may be misconstrued as normal ageing. For a disease associated with age, we hypothesised that the elderly may represent an underdiagnosed population. This study aimed to evaluate this hypothesis by comparing age-stratified estimates of DCM prevalence based on spinal cord compression (SCC) data with hospital-diagnosed prevalence in the UK.We queried the UK Hospital Episode Statistics database for admissions with a primary diagnosis of DCM. Age-stratified incidence rates were calculated and extrapolated to prevalence by adjusting population-level life expectancy to the standardised mortality ratio of DCM. We compared these figures to estimates of DCM prevalence based on the published conversion rate of asymptomatic SCC to DCM.The mean prevalence of DCM across all age groups was 0.19% (0.17, 0.21), with a peak prevalence of 0.42% at age 50-54 years. This contrasts with estimates from SCC data which suggest a mean prevalence of 2.22% (0.436, 2.68) and a peak prevalence of 4.16% at age 79 years.To our knowledge, this is the first study to estimate the age-stratified prevalence of DCM and estimate underdiagnosis. There is a substantial difference between estimates of DCM prevalence derived from SCC data and UK hospital activity data. This is greatest amongst elderly populations, indicating a potential health inequality.

BACKGROUND: Electronic health records are being adopted due to numerous potential benefits. This requires the development of objective metrics to characterize morbidity, comparable to studies performed in centers without an electronic health record. We outline the development of an electronic version of the postoperative morbidity score for integration into our electronic health record. METHODS: Twohundred and three frail patients who underwent elective surgery were reviewed. We retrospectively defined postoperative morbidity score on postoperative day 3. We also recorded potential electronic surrogates for morbidities that could not be easily extracted in an objective format. We compared discriminative capability (area under the receiver operator curve) for patients having prolonged length of stay or complex discharge requirements. RESULTS: One hundred thirty-nine patients (68%) had morbidity in ≥1 postoperative morbidity score domain. Initial electronic surrogates were overly sensitive, identifying 173 patients (84%) as having morbidity. We refined our definitions using backward logistic regression against "gold-standard" postoperative morbidity score. The final electronic postoperative morbidity score differed from the initial version in its definition of cardiac and neurological morbidity. There was no significant difference in the discriminative capability between electronic postoperative morbidity score and postoperative morbidity score for either outcome (area under the receiver operator curve: 0.66 vs 0.66 for complex discharge requirement, area under the receiver operator curve: 0.66 vs 0.67 for a prolonged length of stay; P> .05 for both). Patients with postoperative morbidity score or electronic postoperative morbidity score-defined morbidity on day 3 had increased risk of prolonged length of stay (P < .001 for both). CONCLUSIONS: We present a variant of postoperative morbidity score based on objective electronic metrics. Discriminative performance appeared comparable to gold-standard definitions for discharge outcomes. Electronic postoperative morbidity score may allow characterization of morbidity within our electronic health record, but further study is required to assess external validity.

Introduction Integrated care pathways (ICPs) are a pre-defined framework of evidence based, multidisciplinary practice for specific patients. They have the potential to enhance continuity of care, patient safety, patient satisfaction, efficiency gains, teamwork and staff education. In order to inform the development of neurosurgical ICPs in the future, we performed a systematic review to aggregate examples of neurosurgical ICP, to consider their impact and design features that may be associated with their success. Methods Electronic databases MEDLINE, EMBASE, and CENTRAL were searched for relevant literature published from date of inception to July 2020. Primary studies reporting details of neurosurgical ICPs, across all pathologies and age groups were eligible for inclusion. Patient outcomes in each case were also recorded. Results Twenty-four studies were included in our final dataset, from the United States, United Kingdom, Italy, China, Korea, France, Netherlands and Switzerland, and a number of sub-specialties. 3 for cerebrospinal fluid diversion, 1 functional, 2 neurovascular, 1 neuro-oncology, 2 paediatric, 2 skull base, 10 spine, 1 for trauma, 2 miscellaneous (other craniotomies). All were single centre studies with no regional or national examples. Thirteen were cohort studies while 11 were case series which lacked a control group. Effectiveness was typically evaluated using hospital or professional performance metrics, such as length of stay (n = 11, 45.8%) or adverse events (n = 17, 70.8%) including readmission, surgical complications and mortality. Patient reported outcomes, including satisfaction, were evaluated infrequently (n = 3, 12.5%). All studies reported a positive impact. No study reported how the design of the ICP was informed by published literature or other methods Conclusions ICPs have been successfully developed across numerous neurosurgical sub-specialities. However, there is often a lack of clarity over their design and weaknesses in their evaluation, including an underrepresentation of the patient’s perspective.

Perioperative statistical risk stratification is widespread. Such tools inform intraoperative and postoperative care as part of the National Emergency Laparotomy Audit (NELA)1. Patients with chronic subdural haematomas (cSDH) are often elderly with significant comorbidity2. Despite this, there is a paucity of literature pertaining to risk stratification models in this cohort3. At our centre, as part of a multidisciplinary improvement initiative (the ‘Improving Care in Elderly Neurosurgery Initiative’ (ICENI)4) (Project ID:PRN7705) we demonstrated a significant association between postoperative complications and length of stay2. As a further analysis within this cohort of operated cSDH, we explore the potential of using retrospective electronic health record (EHR) data to generate prognostic statistical models for the identification of two end-organ complications (myocardial injury –troponin above the upper limit of normal and acute kidney injury (AKI) –a rise in serum creatinine of ≥ 1.5 times baseline). Outcomes were chosen based on data availability and veracity as well as clinical relevance. The integrated nature of our EHR permitted incorporation of variables reflecting intraoperative management. This enabled an exploratory analysis of models that, analogous to NELA, could be used preoperatively and updated postoperatively.

IntroductionChronic subdural haematoma (cSDH) tends to occur in older patients, often with significant comorbidity. The incidence and effect of medical complications as well as the impact of intraoperative management strategies are now attracting increasing interest.ObjectivesWe used electronic health record data to study the profile of in-hospital morbidity and examine associations between various intraoperative events and postoperative stay.Design, setting and participantsSingle-centre, retrospective cohort of 530 cases of cSDH (2014–2019) surgically evacuated under general anaesthesia at a neurosciences centre in Cambridge, UK.Methods and outcome definitionComplications were defined using a modified Electronic Postoperative Morbidity Score. Association between complications and intraoperative care (time with mean arterial pressure 2) range of 3–5 kPa, maintenance anaesthetic, operative time and opioid dose) on postoperative stay was assessed using Cox regression.Results53 (10%) patients suffered myocardial injury, while 24 (4.5%) suffered acute renal injury. On postoperative day 3 (D3), 280 (58% of remaining) inpatients suffered at least 1 complication. D7 rate was comparable (57%). Operative time was the only intraoperative event associated with postoperative stay (HR for discharge: 0.97 (95% CI: 0.95 to 0.99)). On multivariable analysis, postoperative complications (0.61 (0.55 to 0.68)), anticoagulation (0.45 (0.37 to 0.54)) and cognitive impairment (0.71 (0.58 to 0.87)) were associated with time to discharge.ConclusionsThere is a high postoperative morbidity burden in this cohort, which was associated with postoperative stay. We found no evidence of an association between intraoperative events and postoperative stay.

Objective Degenerative cervical myelopathy (DCM) is a disabling neurological condition. The underlying degenerative changes are known to be more common with age, but the impact of age on clinical aspects of DCM has never been synthesised. The objective of this study is to determine whether age is a significant predictor in three domains—clinical presentation, surgical management and post-operative outcomes of DCM. Methods a systematic review of the Medline and Embase databases (inception to 12 December 2019), registered with PROSPERO (CRD42019162077) and reported in accordance with preferred reporting items of systematic reviews and meta-analysis (PRISMA) guidelines, was conducted. The inclusion criteria were full text articles in English, evaluating the impact of age on clinical aspects of DCM. Results the initial search yielded 2,420 citations, of which 206 articles were eventually included. Age was found to be a significant predictor in a variety of measures. Within the presentation domain, older patients have a worse pre-operative functional status. Within the management domain, older patients are more likely to undergo posterior surgery, with more levels decompressed. Within the outcomes domain, older patients have a worse post-operative functional status, but a similar amount of improvement in functional status. Because of heterogenous data reporting, meta-analysis was not possible. Conclusion the current evidence demonstrates that age significantly influences the presentation, management and outcomes of DCM. Although older patients have worse health at all individual timepoints, they experience the same absolute benefit from surgery as younger patients. This finding is of particular relevance when considering the eligibility of older patients for surgery.

The COVID-19 pandemic has led to unprecedented strain on intensive care unit (ICU) admission in parts of the world. Strategies to create surge ICU capacity require complex local and national service reconfiguration and reduction or cancellation of elective activity. These measures have an inevitable lag-time before additional capacity comes on-line. An accurate short-range forecast would be helpful in guiding such difficult, costly, and ethically challenging decisions.At the time this work began, cases in England were starting to increase. If this represents a true spread in disease then ICU demand could increase rapidly. Here we present a short-range forecast based on published real-time COVID-19 case data from the seven National Health Service (NHS) commissioning regions in England (East of England, London, Midlands, North East and Yorkshire, North West, South East and South West). We use a Monte Carlo approach to model the likely impact of current diagnoses on regional ICU capacity over a 14-day horizon under the assumption that the increase in cases represents the start of an exponential growth in infections. Our model is designed to be parsimonious and based on available epidemiological data from the literature at the moment.On the basis of the modelling assumptions made, ICU occupancy is likely to increase dramatically in the days following the time of modelling. If the current exponential growth continues, case numbers will be comparable to current ICU bed numbers within weeks. Despite variable growth in absolute patients, all commissioning regions are forecast to be heavily burdened under the assumptions used.Whilst, like any forecast model, there remain uncertainties both in terms of model specification and robust epidemiological data in this early prospective phase, it would seem that surge capacity will be required in the very near future. Our findings should be interpreted with caution, but we hope that our model will help policy decision makers with their preparations. The uncertainties in the data highlight the urgent need for ongoing real-time surveillance to allow forecasts to be constantly updated using high quality local patient-facing data as it emerges.

OBJECTIVES: To explore the frequency and nature of complaints and compliments reported to Patient Advice and Liaison (PALS) in individuals undergoing surgery for a chronic subdural haematoma (cSDH). DESIGN: A retrospective study of PALS user interactions. SUBJECTS: Individuals undergoing treatment for cSDH between 2014 and 2019. METHODS: PALS referrals from patients with cSDH between 2014 and 2019 were identified. Case records were reviewed and data on the frequency, nature and factors leading up to the complaint were extracted and coded according to Healthcare Complaints Analysis Tool (HCAT). RESULTS: Out of 531 patients identified, 25 (5%) had a PALS interaction, of which 15 (3%) were complaints and 10 (2%) were compliments. HCAT coding showed 8/15 (53%) of complaints were relationship problems, 6/15 (33%) a management problem and 1/15 (7%) other. Of the relationship problems, 6 (75%) were classed as problems with communication and 2 (25%) as a problem with listening. Of the compliments, 9/10 (90%) related to good clinical quality and 1/10 (10%) to staff-patient relationship. Patients were more likely to register a compliment than family members, who in turn were more likely to register a complaint (p, NIHR Clinical Doctoral Research Fellowship

Summary We previously defined surgical list ‘efficiency’ as: maximising theatre utilisation, minimising over-running, and minimising cancellations. ‘Efficiency’ maximises output for input; ‘productivity’ emphasises total output. We define six criteria that any measure of productivity (better termed ‘quantitative performance’) needs to satisfy. We then present a theoretical analysis that fulfils these by incorporating: ‘speed’ of surgery (with reference to average speeds), ‘patient contact’ (synonymous with minimising gaps between cases), and ‘efficiency’ (as previously defined). ‘Speed’ and ‘patient contact’ together constitute a ‘productive potential’. Our formula satisfies the pre-set criteria and yields plausible results in both hypothetical and real data sets, To be productive in these quantitative terms, teams in any specialty need to achieve minimum quality standards defined by their sub-specialty; to plan their lists to utilise the time available with no cancellations or over-runs and to work at least as fast as average with minimal gaps between cases. ‘Productive potential’ combined with ‘efficiency’ yielding ‘actual productivity’ in our theoretical analysis more completely describes quantitative surgical list performance than any other single measure.

Summary While some speculation surrounds annual private practice incomes of anaesthetists, little is known of the hours of work needed to generate any presumed income (the hourly rate). The benefit maxima of five private medical insurers are published in fee schedules and data on the duration of common operations are now also known. In this study we combined these to generate estimates for hourly rates of reimbursement across 78 common operations in eight surgical subspecialties, for anaesthetists and surgeons. We expected to find significant differences between insurers as a result of market competition, and we expected differences between anaesthetists and surgeons. The median (IQR [range]) rate of reimbursement for anaesthetists was £167 (132–211 [68–570]).h−1 with significant variation across subspecialties (p 0.17). Patterns of reimbursement for surgeons were similar to those for anaesthetists, except that surgeons were reimbursed at about twice the rate. We conclude there is a confluence of insurer reimbursement levels and we discuss potential implications of this finding. Our results also have implications for how incentives between the NHS and private practice, or within a private practice group, might be optimally managed.

Sepsis-associated encephalopathy (SAE) refers to a clinical spectrum of acute neurological dysfunction that arises in the context of sepsis. Although the pathophysiology of SAE is incompletely understood, it is thought to involve endothelial activation, blood-brain barrier leakage, inflammatory cell migration, and neuronal loss with neurotransmitter imbalance. SAE is associated with a high risk of mortality. Imaging studies using MRI and CT have demonstrated changes in the brains of patients with SAE that are also seen in disorders such as stroke. Next-generation imaging techniques such as magnetic resonance spectroscopy, diffusion tensor imaging and PET, as well as experimental imaging modalities, provide options for early identification of patients with SAE, and could aid in identification of pathophysiological processes that represent possible therapeutic targets. In this Review, we explore the recent literature on imaging in SAE, relating the findings of these studies to pathological data and experimental studies to obtain insights into the pathophysiology of sepsis-associated neurological dysfunction. Furthermore, we suggest how novel imaging technologies can be used for early-stage proof-of-concept and proof-of-mechanism translational studies, which may help to improve diagnosis in SAE.

There is evidence for interaction between the developing circulatory and nervous systems. Blood vessels provide a supporting niche in regions of adult neurogenesis. Here we present a systematic analysis of vascular development in the embryonic murine cortex and demonstrate that dividing cells, including Tbr2-positive intermediate progenitor cells, are closer to the vasculature than expected from a random distribution. To examine whether neurites of the newly generated embryonic neurons find blood vessels as an attractive and permissive substrate, we overlayed green fluorescent protein (GFP)-labeled dissociated cortical progenitors on embryonic organotypic cortical slice cultures with labeled vasculature. Our observations of neurites extending toward and along labeled blood vessels support the notion of vascular-neuronal interactions. The altered cortical layering had no obvious effect on the vascular patterns within the cortical plate (CP) in shaking rat Kawasaki (SRK) and the reeler mutant mouse at the ages studied (E19 and P3). It appears that similarly to other neurogenic regions in the adult, the embryonic "vascular niche" might influence neural progenitor cells during telencephalic neurogenesis, neuronal migration, and neurite extension, but the laminar phenotype of cell classes within the CP has limited influence on the developing vasculature.