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Covell MM, Roy JM, Gupta N, Raihane AS, Rumalla KC, Lima Fonseca Rodrigues AC, Courville E, Bowers CA. Frailty in intracranial meningioma resection: the risk analysis index demonstrates strong discrimination for predicting non-home discharge and in-hospital mortality. J Neurooncol 2024:10.1007/s11060-024-04703-5. [PMID: 38713325 DOI: 10.1007/s11060-024-04703-5] [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: 03/30/2024] [Accepted: 04/30/2024] [Indexed: 05/08/2024]
Abstract
PURPOSE Frailty is an independent risk factor for adverse postoperative outcomes following intracranial meningioma resection (IMR). The role of the Risk Analysis Index (RAI) in predicting postoperative outcomes following IMR is nascent but may inform preoperative patient selection and surgical planning. METHODS IMR patients from the Nationwide Inpatient Sample were identified using diagnostic and procedural codes (2019-2020). The relationship between preoperative RAI-measured frailty and primary outcomes (non-home discharge (NHD), in-hospital mortality) and secondary outcomes (extended length of stay (eLOS), complication rates) was assessed via multivariate analyses. The discriminatory accuracy of the RAI for primary outcomes was measured in area under the receiver operating characteristic (AUROC) curve analysis. RESULTS A total of 23,230 IMR patients (mean age = 59) were identified, with frailty statuses stratified by RAI score: 0-20 "robust" (R)(N = 10,665, 45.9%), 21-30 "normal" (N)(N = 8,895, 38.3%), 31-40 "frail" (F)(N = 2,605, 11.2%), and 41+ "very frail" (VF)(N = 1,065, 4.6%). Rates of NHD (R 11.5%, N 29.7%, F 60.8%, VF 61.5%), in-hospital mortality (R 0.5%, N 1.8%, F 3.8%, VF 7.0%), eLOS (R 13.2%, N 21.5%, F 40.9%, VF 46.0%), and complications (R 7.5%, N 11.6%, F 15.7%, VF 16.0%) significantly increased with increasing frailty thresholds (p < 0.001). The RAI demonstrated strong discrimination for NHD (C-statistic: 0.755) and in-hospital mortality (C-statistic: 0.754) in AUROC curve analysis. CONCLUSION Increasing RAI-measured frailty is significantly associated with increased complication rates, eLOS, NHD, and in-hospital mortality following IMR. The RAI demonstrates strong discrimination for predicting NHD and in-hospital mortality following IMR, and may aid in preoperative risk stratification.
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Affiliation(s)
- Michael M Covell
- School of Medicine, Georgetown University, 3900 Reservoir Road, 20007, Washington, DC, USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, 84070, Sandy, UT, USA
| | - Joanna M Roy
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, 84070, Sandy, UT, USA
| | - Nithin Gupta
- Campbell University School of Osteopathic Medicine, Lillington, NC, USA
| | - Ahmed Sami Raihane
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, 84070, Sandy, UT, USA
| | - Kranti C Rumalla
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, 84070, Sandy, UT, USA
| | | | - Evan Courville
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, 84070, Sandy, UT, USA
| | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, 84070, Sandy, UT, USA.
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Iqbal J, Shafique MA, Mustafa MS, Covell MM, Fatima A, Saboor HA, Nadeem A, Iqbal A, Iqbal MF, Rangwala BS, Hafeez MH, Bowers CA. Neurosurgical Malpractice Litigation: A Systematic Review and Meta-Analysis. World Neurosurg 2024:S1878-8750(24)00685-5. [PMID: 38685351 DOI: 10.1016/j.wneu.2024.04.112] [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: 03/24/2024] [Revised: 04/16/2024] [Accepted: 04/17/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND & OBJECTIVES Neurosurgery has one of the highest risks for medical malpractice claims. We reviewed the factors associated with neurosurgical malpractice claims and litigation in the United States of America (USA) and reported the outcomes through a systematic review of the literature. METHODS We conducted a systematic review of the literature according to the PRISMA guidelines using the Medline, Embase, Cochrane, PubMed, and Google Scholar databases. We sought to identify pertinent studies containing information about medical malpractice claims and outcomes involving neurosurgeons in the USA. RESULTS We identified 15 retrospective studies spanning from 2002 to 2023 that reviewed over 7,890 malpractice claims involving practicing neurosurgeons in the USA. Disparities were evident in neurosurgical litigation, with 474 cases linked to brain-related surgeries and a larger proportion, 1926 cases, tied to spine surgeries. The most commonly filed claims were intra-procedural errors (37.4%), delayed diagnoses (32.1%), and failure to treat (28.8 %). Less frequently filed claims included misdiagnosis or choice of incorrect procedure (18.4%), occurrence of death (17.3%), test misinterpretation (14.4%), failure to appropriately refer patients for evaluation/treatment (14.3%), unnecessary surgical procedures (13.3 %), and lack of informed consent (8.3%). The defendant was favored in 44.3% of claims, while 31.3% of lawsuits, 17.7% of verdicts favored the plaintiff, and 16.6% reached an out-of-court settlement. Only 3.5% of lawsuits found both parties liable. CONCLUSION Neurosurgery is a high-risk specialty with one of the highest rates of malpractice claims. Spine claims had a significantly higher rate of filed malpractice claims, while cranial malpractice claims were associated with higher litigation compensation. Predictably, spinal cord injuries play a crucial role in predicting litigation. Importantly, nonsurgical treatments are also a common source of liability in neurosurgical practice.
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Affiliation(s)
- Javed Iqbal
- King Edward Medical University, Lahore, Pakistan.
| | | | | | | | - Afia Fatima
- Jinnah Sindh Medical University, Karachi, Pakistan
| | | | | | - Ather Iqbal
- Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | | | | | | | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, UT 87122
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Covell MM, Gajjar AA, Sioutas GS, Burkhardt JK, Srinivasan VM. Improper National Inpatient Sample ICD-10 coding limits comparative value of impact of ARUBA trial on prevalence and rupture rates of arteriovenous malformations. J Neurointerv Surg 2024; 16:532-534. [PMID: 37898552 DOI: 10.1136/jnis-2023-021006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/20/2023] [Indexed: 10/30/2023]
Affiliation(s)
- Michael M Covell
- School of Medicine, Georgetown University, Washington, District of Columbia, USA
| | - Avi A Gajjar
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Georgios S Sioutas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Rumalla KC, Covell MM, Skandalakis GP, Rumalla K, Kassicieh AJ, Roy JM, Kazim SF, Segura A, Bowers CA. The frailty-driven predictive model for failure to rescue among patients who experienced a major complication following cervical decompression and fusion: an ACS-NSQIP analysis of 3,632 cases (2011-2020). Spine J 2024; 24:582-589. [PMID: 38103740 DOI: 10.1016/j.spinee.2023.12.003] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/03/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND CONTEXT Preoperative risk stratification for patients considering cervical decompression and fusion (CDF) relies on established independent risk factors to predict the probability of complications and outcomes in order to help guide pre and perioperative decision-making. PURPOSE This study aims to determine frailty's impact on failure to rescue (FTR), or when a mortality occurs within 30 days following a major complication. STUDY DESIGN/SETTING Cross-sectional retrospective analysis of retrospective and nationally-representative data. PATIENT SAMPLE The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all CDF cases from 2011-2020. OUTCOME MEASURES CDF patients who experienced a major complication were identified and FTR was calculated as death or hospice disposition within 30 days of a major complication. METHODS Frailty was measured by the Risk Analysis Index-Revised (RAI-Rev). Baseline patient demographics and characteristics were compared for all FTR patients. Significant factors were assessed by univariate and multivariable regression for the development of a frailty-driven predictive model for FTR. The discriminative ability of the predictive model was assessed using a receiving operating characteristic (ROC) curve analysis. RESULTS There were 3632 CDF patients who suffered a major complication and 7.6% (277 patients) subsequently expired or dispositioned to hospice, the definition of FTR. Independent predictors of FTR were nonelective surgery, frailty, preoperative intubation, thrombosis or embolic complication, unplanned intubation, on ventilator for >48 hours, cardiac arrest, and septic shock. Frailty, and a combination of preoperative and postoperative risk factors in a predictive model for FTR, achieved outstanding discriminatory accuracy (C-statistic = 0.901, CI: 0.883-0.919). CONCLUSION Preoperative and postoperative risk factors, combined with frailty, yield a highly accurate predictive model for FTR in CDF patients. Our model may guide surgical management and/or prognostication regarding the likelihood of FTR after a major complication postoperatively with CDF patients. Future studies may determine the predictive ability of this model in other neurosurgical patient populations.
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Affiliation(s)
- Kranti C Rumalla
- Feinberg School of Medicine, Northwestern University, 420 E Superior St., Chicago, IL, 60611, USA
| | - Michael M Covell
- School of Medicine, Georgetown University, 3900 Reservoir Road NW, Washington, DC, 20007, USA
| | - Georgios P Skandalakis
- Department of Neurosurgery, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
| | - Alexander J Kassicieh
- Department of Neurosurgery, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
| | - Joanna M Roy
- Topiwala National Medical College, Mumbai Central, Mumbai, Maharashtra 400008, India
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
| | - Aaron Segura
- Department of Neurosurgery, University of New Mexico Hospital, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
| | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, 8342 S Levine Ln, Sandy, UT, 84070, USA.
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Gajjar AA, Covell MM, Muhammad N, Kuo C, Sioutas GS, Salem MM, Fras SI, Jankowitz BT, Burkhardt JK, Srinivasan VM. Utilization and reimbursement of diagnostic cerebral angiograms: A Medicare trends analysis from 2013 to 2020. Interv Neuroradiol 2024:15910199241233333. [PMID: 38389425 DOI: 10.1177/15910199241233333] [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] [Indexed: 02/24/2024] Open
Abstract
INTRODUCTION Increasing life expectancy has caused growing concern about maintaining viable neurointerventional practices due to altered Medicare payment structures. This study analyzes the financial trends of three common diagnostic tests for cerebrovascular disease: cerebral digital subtraction angiography (DSA), computed tomography angiography (CTA), and magnetic resonance angiography (MRA). METHODS Medicare Part B National Summary Data files from 2013 to 2020 were queried by Current Procedural Terminology (CPT) codes for DSA (36221-36228), CTA (70496, 70498), and MRA (70544-70547, 70549). Inflation-adjusted charges and reimbursement were calculated using the U.S. City Average Consumer Price Index for Medical Services. Regression analysis was performed on charges, reimbursement, and volume. RESULTS A total of 1,519,245 diagnostic procedures were conducted between 2013 and 2020 (782,370 angiograms, 246,603 CTAs, and 490,272 MRAs). A total of $41.005 million was reimbursed by Medicare in 2020 for these diagnostic procedures. The annual percent change in volume for all procedures was -2.90%. From 2013 to 2020, inflation-adjusted: Medicare total physician reimbursement decreased for cerebral angiograms (-4.12%, p = 0.007), CTAs (-2.77%, p = 0.458), and MRAs (-9.06%, p < 0.001). Procedural volume billed to Medicare decreased for cerebral angiograms (-4.63%, p = 0.007) and MRAs (-2.94%, p = 0.0.81) and increased for CTAs (+3.15%, p = 0.004). The greatest increase in Medicare reimbursement (+66.75%) came from CPT code 36224, "place catheter carotid artery", and the greatest decrease in Medicare reimbursement (-8.66%) came from CPT code 36226, "place catheter vertebral artery." CONCLUSIONS This study provides an analysis of Medicare reimbursement trends for routine cerebrovascular angiogram techniques. The findings highlight a decline in Medicare reimbursements for neurointerventionalists.
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Affiliation(s)
- Avi A Gajjar
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael M Covell
- Department of Neurosurgery, School of Medicine, Georgetown University, Washington, D.C., USA
| | - Najib Muhammad
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Cathleen Kuo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Georgios S Sioutas
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mohamed M Salem
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sebastian Ivan Fras
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Covell MM, Roy JM, Rumalla K, Dicpinigaitis AJ, Kazim SF, Hall DE, Schmidt MH, Bowers CA. The Limited Utility of the Hospital Frailty Risk Score as a Frailty Assessment Tool in Neurosurgery: A Systematic Review. Neurosurgery 2024; 94:251-262. [PMID: 37695046 DOI: 10.1227/neu.0000000000002668] [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] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/13/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The Hospital Frailty Risk Score (HFRS) is an International Classification of Disease 10th Revision-based scale that was originally designed for, and validated in, the assessment of patients 75 years or older presenting in an acute care setting. This study highlights central tenets inherent to the concept of frailty; questions the logic behind, and utility of, HFRS' recent implementation in the neurosurgical literature; and discusses why there is no useful role for HFRS as a frailty-based neurosurgical risk assessment (FBNRA) tool. METHODS The authors performed a systematic review of the literature per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including all cranial and spinal studies that used HFRS as their primary frailty tool. Seventeen (N = 17) studies used HFRS to assess frailty's impact on neurosurgical outcomes. Thirteen total journals, 10 of which were neurosurgical journals, including the highest impact factor journals, published the 17 papers. RESULTS Increasing HFRS score was associated with adverse outcomes, including prolonged length of stay (11 of 17 studies), nonroutine discharge (10 of 17 studies), and increased hospital costs (9 of 17 studies). Four different HFRS studies, of the 17, predicted one of the following 4 adverse outcomes: worse quality of life, worse functional outcomes, reoperation, or in-hospital mortality. CONCLUSION Despite its rapid acceptance and widespread proliferation through the leading neurosurgical journals, HFRS lacks any conceptual relationship to the frailty syndrome or FBNRA for individual patients. HFRS measures acute conditions using International Classification of Disease 10th Revision codes and awards "frailty" points for symptoms and examination findings unrelated to the impaired baseline physiological reserve inherent to the very definition of frailty. HFRS lacks clinical utility as it cannot be deployed point-of-care at the bedside to risk stratify patients. HFRS has never been validated in any patient population younger than 75 years or in any nonacute care setting. We recommend HFRS be discontinued as an individual FBNRA tool.
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Affiliation(s)
- Michael M Covell
- School of Medicine, Georgetown University, Washington , District of Columbia , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Joanna Mary Roy
- Topiwala National Medical College, Mumbai , India
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Alis J Dicpinigaitis
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla , New York , USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
- Center for Health Equity Research and Promotion, Virginia Pittsburgh Healthcare System, Pittsburgh , Pennsylvania , USA
- Wolff Center at UPMC, Pittsburgh , Pennsylvania , USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
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Roy JM, Covell MM, Venero C, Bowers CA. A Medical Student's Guide to Online Resources in Neurosurgery. World Neurosurg 2024; 181:23-28. [PMID: 37832635 DOI: 10.1016/j.wneu.2023.10.024] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023]
Abstract
Early exposure to neurosurgery during medical school is critical to improving recruitment into the specialty. About 30% of medical schools in the U.S. lack a home program in neurosurgery, thereby, limiting their exposure to the field of neurosurgery. The transition to virtual education was largely facilitated through webinars during the coronavirus disease of 2019 pandemic. Advantages of these resources include their widespread global outreach, with a large number of attendees being international medical students. Although many such resources exist, they are primarily available through social media platforms. To our knowledge, there exists no clear outline of these resources. We identified 16 resources through a database search and through popular social media platforms. Nine out of 16 resources were video based, and 2 utilized the concept of spaced repetition through flashcards. Our review describes these educational resources and aims to serve as a guide for medical students interested in neurosurgery.
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Affiliation(s)
- Joanna M Roy
- Topiwala National Medical College, Mumbai, India; Bowers Neurosurgical Frailty & Outcomes Data Science Lab, Albuquerque, New Mexico, USA
| | - Michael M Covell
- Bowers Neurosurgical Frailty & Outcomes Data Science Lab, Albuquerque, New Mexico, USA; School of Medicine, Georgetown University, Washington, District of Columbia, USA
| | - Carmelo Venero
- Bowers Neurosurgical Frailty & Outcomes Data Science Lab, Albuquerque, New Mexico, USA; University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Christian A Bowers
- Bowers Neurosurgical Frailty & Outcomes Data Science Lab, Albuquerque, New Mexico, USA.
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Iqbal J, Covell MM, Jabeen S, Nadeem A, Malik Gunjial H, Abdus Saboor H, Amin A, Salman Y, Hafeez MH, Bowers CA. Comparative analysis of exoscope-assisted spine surgery versus operating microscope: A systematic review. World Neurosurg X 2024; 21:100258. [PMID: 38173684 PMCID: PMC10762452 DOI: 10.1016/j.wnsx.2023.100258] [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: 10/31/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024] Open
Abstract
Background Limitations in the operative microscope (OM)'s mobility and suboptimal ergonomics created the opportunity for the development of the exoscope. This systematic review aims to evaluate the advantages and disadvantages of exoscopes and OMs in spine surgery. Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic search was conducted in the major research databases. All studies evaluating the exoscopes and/or OMs in spinal procedures were included. Results There were 602 patients included in the 16 studies, with 539 spine surgery patients, 19 vascular cases, 1 neural pathology case, 19 cranial cases, and 24 tumor pathologies. When examining surgical outcomes with the exoscope, results were mixed. Compared to the OM, exoscope usage resulted in longer operative times in 7 studies, comparable times in 3 studies, and shorter operative times in 3 studies. Two studies found similar lengths of stay (LOS) for both tools, two reported longer LOS with exoscopes, and one indicated shorter hospital LOS with exoscopes. One study reported higher exoscope-related blood loss (EBL), but four other studies consistently showed reduced EBL. In terms of image quality, illumination, dynamic range, depth perception, ergonomics and cost-effectiveness, the exoscope was consistently rated superior, while findings across studies were mixed regarding the optical zoom ratio and mean scope adjustment (MSA). The learning curve for exoscope use was consistently reported as shorter in all studies. Conclusion Exoscopes present a viable alternative to OMs in spine surgery, offering multiple advantages, which supports their promising role in modern neurosurgical practice.
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Affiliation(s)
- Javed Iqbal
- King Edward Medical University, Lahore, Pakistan
| | | | - Sidra Jabeen
- Liaquat National Hospital and Medical College, Karachi, Pakistan
| | | | | | | | - Aamir Amin
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Yumna Salman
- Dow University of Health Sciences, Karachi, Pakistan
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Lauinger AR, Naik A, Bah MG, Eltinay MNE, Covell MM, Catapano J, Grande AW, Arnold PM. Letter: Trends in In-Hospital Mortality and Neurological Deficit Rates Following Ischemic Stroke in Low- and Middle-Income Countries. Neurosurgery 2024; 94:e9-e12. [PMID: 37947422 DOI: 10.1227/neu.0000000000002745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 11/12/2023] Open
Affiliation(s)
| | - Anant Naik
- Department of Neurological Surgery, University of Minnesota Twin Cities, Minneapolis , Minnesota , USA
| | - Momodou G Bah
- Michigan State University College of Human Medicine, East Lansing , Michigan , USA
| | | | - Michael M Covell
- School of Medicine, Georgetown University, Washington , District of Columbia , USA
| | - Joshua Catapano
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix , Arizona , USA
| | - Andrew W Grande
- Department of Neurological Surgery, University of Minnesota Twin Cities, Minneapolis , Minnesota , USA
| | - Paul M Arnold
- Department of Neurological Surgery, Carle Neuroscience Institute, Urbana , Illinois , USA
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Gajjar AA, Covell MM, Salem MM, Sioutas GS, Hasan S, Dinh Le AH, Srinivasan VM, Burkhardt JK. Patient sentiment regarding stroke: Analysis of 2,992 social media posts. J Stroke Cerebrovasc Dis 2023; 32:107376. [PMID: 37813085 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107376] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/05/2023] [Accepted: 09/15/2023] [Indexed: 10/11/2023] Open
Abstract
INTRODUCTION Social media reflects personalized sentiment toward disease and increasingly impacts perceptions of treatment options. This study aims to assess patients experience with and perception of stroke through an analysis of social media posts. METHODS A variety of terms ("stroke", "stroke survivor", "stroke rehab", "stroke recovery") were used to search for possible qualified posts on Twitter and Instagram. Twitter posts containing "#stroke" and "@stroke" were identified, yielding 2,506 Twitter posts relating to the patient's own experience. Four hundred sixty-eight public Instagram posts marked under "#stroke" and "@stroke," including direct references to the patient's own experience, were analyzed. First vs. recurrent stroke was identified when possible. The posts were coded for themes relating to patient experience with the disease. RESULTS The most common Twitter theme was raising stroke awareness (23.4 %), while spreading positivity was the most common Instagram theme (66.7 %). Most Twitter posts (93.9 %) were from patients experiencing their first stroke, with only 6.1 % of the posts being about recurrent strokes. Women created the majority of Instagram (75.7 %) and Twitter (77.3 %) posts. Men were more likely to discuss mobility/functional outcomes (p = 0.001) and survival/death (p = 0.014), while women were more likely to recount symptoms (p = 0.014), depression (p = 0.002), fear (p<0.001), and mental health (p = 0.006). CONCLUSION Stroke patients most often describe their quality of life and discuss raising awareness via social media. Men and women differ in the most commonly shared aspects of their stroke experience. Gauging social media sentiment may guide physicians toward better counseling and psychosocial management of stroke patients.
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Affiliation(s)
- Avi A Gajjar
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Michael M Covell
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA; School of Medicine, Georgetown University, Washington, D.C., USA
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Georgios S Sioutas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Sidra Hasan
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA; Department of Biology, Union College, Schenectady, New York, USA
| | - Anthony Huy Dinh Le
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA.
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Roy JM, Segura AC, Rumalla K, Skandalakis GP, Covell MM, Bowers CA. A Predictive Model of Failure to Rescue After Thoracolumbar Fusion. Neurospine 2023; 20:1337-1345. [PMID: 38171301 PMCID: PMC10762394 DOI: 10.14245/ns.2346840.420] [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: 08/15/2023] [Revised: 09/30/2023] [Accepted: 10/01/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE Although failure to rescue (FTR) has been utilized as a quality-improvement metric in several surgical specialties, its current utilization in spine surgery is limited. Our study aims to identify the patient characteristics that are independent predictors of FTR among thoracolumbar fusion (TLF) patients. METHODS Patients who underwent TLF were identified using relevant diagnostic and procedural codes from the National Surgical Quality Improvement Program (NSQIP) database from 2011-2020. Frailty was assessed using the risk analysis index (RAI). FTR was defined as death, within 30 days, following a major complication. Univariate and multivariable analyses were used to compare baseline characteristics and early postoperative sequelae across FTR and non-FTR cohorts. Receiver operating characteristic (ROC) curve analysis was used to assess the discriminatory accuracy of the frailty-driven predictive model for FTR. RESULTS The study cohort (N = 15,749) had a median age of 66 years (interquartile range, 15 years). Increasing frailty, as measured by the RAI, was associated with an increased likelihood of FTR: odds ratio (95% confidence interval [CI]) is RAI 21-25, 1.3 [0.8-2.2]; RAI 26-30, 4.0 [2.4-6.6]; RAI 31-35, 7.0 [3.8-12.7]; RAI 36-40, 10.0 [4.9-20.2]; RAI 41- 45, 21.5 [9.1-50.6]; RAI ≥ 46, 45.8 [14.8-141.5]. The frailty-driven predictive model for FTR demonstrated outstanding discriminatory accuracy (C-statistic = 0.92; CI, 0.89-0.95). CONCLUSION Baseline frailty, as stratified by type of postoperative complication, predicts FTR with outstanding discriminatory accuracy in TLF patients. This frailty-driven model may inform patients and clinicians of FTR risk following TLF and help guide postoperative care after a major complication.
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Affiliation(s)
- Joanna M. Roy
- Topiwala National Medical College, Mumbai, India
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, USA
| | - Aaron C. Segura
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, USA
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Kranti Rumalla
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, USA
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Georgios P. Skandalakis
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, USA
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Michael M. Covell
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, USA
- School of Medicine, Georgetown University, Washington, DC, USA
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Covell MM, Naik A, Shaffer A, Cramer SW, Alan N, Shabani HK, Rabiel H, Rosseau G, Arnold PM. Social Determinants of Health Impact Spinal Cord Injury Outcomes in Low- and Middle-Income Countries: A Meta-Epidemiological Study. Neurosurgery 2023:00006123-990000000-00960. [PMID: 37962339 DOI: 10.1227/neu.0000000000002765] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/02/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Traumatic spinal cord injuries (SCI), which disproportionally occur in low- and middle-income countries (LMICs), pose a significant global health challenge. Despite the prevalence and severity of SCI in these settings, access to appropriate surgical care and barriers to treatment remain poorly understood on a global scale, with data from LMICs being particularly scarce and underreported. This study sought to examine the impact of social determinants of health (SDoH) on the pooled in-hospital and follow-up mortality, and neurological outcomes, after SCI in LMICs. METHODS A systematic review was conducted in adherence to the Preferred Reporting in Systematic Review and Meta-Analysis-guidelines. Multivariable analysis was performed by multivariable linear regression, investigating the impact of the parameters of interest (patient demographics, country SDoH characteristics) on major patient outcomes (in-hospital/follow-up mortality, neurological dysfunction). RESULTS Forty-five (N = 45) studies were included for analysis, representing 13 individual countries and 18 134 total patients. The aggregate pooled in-hospital mortality rate was 6.46% and 17.29% at follow-up. The in-hospital severe neurological dysfunction rate was 97.64% and 57.36% at follow-up. Patients with rural injury had a nearly 4 times greater rate of severe in-hospital neurological deficits than patients in urban areas. The Gini index, reflective of income inequality, was associated with a 23.8% increase in in-hospital mortality, a 20.1% decrease in neurological dysfunction at follow-up, and a 12.9% increase in mortality at follow-up. CONCLUSION This study demonstrates the prevalence of injury and impact of SDoH on major patient outcomes after SCI in LMICs. Future initiatives may use these findings to design global solutions for more equitable care of patients with SCI.
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Affiliation(s)
- Michael M Covell
- School of Medicine, Georgetown University, Washington, District of Columbia, USA
| | - Anant Naik
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Annabelle Shaffer
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Samuel W Cramer
- Department of Neurosurgery, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Nima Alan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Hamisi K Shabani
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Happiness Rabiel
- Department of Neurosurgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Gail Rosseau
- Department of Neurosurgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Paul M Arnold
- Department of Neurosurgery, Carle Foundation Hospital, Urbana, Illinois, USA
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Wong GM, Cobourn K, Smith K, Covell MM, Dowlati E, Breton JM, Pivazyan G, Nair MN. Reducing implicit bias in the neurosurgery application and interview process: a single-institution experience. Neurosurg Focus 2023; 55:E14. [PMID: 37913534 DOI: 10.3171/2023.8.focus23414] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/24/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE The neurosurgical match is a challenging process for applicants and programs alike. Programs must narrow a wide field of applicants to interview and then determine how to rank them after limited interaction. To streamline this, programs commonly screen applicants using United States Medical Licensing Examination (USMLE) Step scores. However, this approach removes nuance from a consequential decision and exacerbates existing biases. The primary objective of this study was to demonstrate the feasibility of effecting minor modifications to the residency application process, as the authors have done at their institution, specifically by reducing the prominence of USMLE board scores and Alpha Omega Alpha (AΩA) status, both of which have been identified as bearing racial biases. METHODS At the authors' institution, residents and attendings holistically reviewed applications with intentional redundancy so that every file was reviewed by two individuals. Reviewers were blinded to applicants' photographs and test scores. On interview day, the applicant was evaluated for their strength in three domains: knowledge, commitment to neurosurgery, and integrity. For rank discussions, applicants were reviewed in the order of their domain scores, and USMLE scores were unblinded. A regression analysis of the authors' rank list was made by regressing the rank list by AΩA status, Step 1 score, Step 2 score, subinternship, and total interview score. RESULTS No variables had a significant effect on the rank list except total interview score, for which a single-point increase corresponded to a 15-position increase in rank list when holding all other variables constant (p < 0.05). CONCLUSIONS The goal of this holistic review and domain-based interview process is to mitigate bias by shifting the focus to selected core qualities in lieu of traditional metrics. Since implementation, the authors' final rank lists have closely reflected the total interview score but were not significantly affected by board scores or AΩA status. This system allows for the removal of known sources of bias early in the process, with the aim of reducing potential downstream effects and ultimately promoting a final list that is more reflective of stated values.
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Affiliation(s)
- Georgia M Wong
- 1Department of Neurosurgery, Georgetown University School of Medicine
| | - Kelsey Cobourn
- 2Department of Neurosurgery, MedStar Georgetown University Hospital; and
- 3Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC
| | - Kitara Smith
- 1Department of Neurosurgery, Georgetown University School of Medicine
| | - Michael M Covell
- 1Department of Neurosurgery, Georgetown University School of Medicine
| | - Ehsan Dowlati
- 2Department of Neurosurgery, MedStar Georgetown University Hospital; and
- 3Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC
| | - Jeffrey M Breton
- 2Department of Neurosurgery, MedStar Georgetown University Hospital; and
- 3Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC
| | - Gnel Pivazyan
- 2Department of Neurosurgery, MedStar Georgetown University Hospital; and
- 3Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC
| | - M Nathan Nair
- 1Department of Neurosurgery, Georgetown University School of Medicine
- 2Department of Neurosurgery, MedStar Georgetown University Hospital; and
- 3Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC
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Roy JM, Bowers CA, Rumalla K, Covell MM, Kazim SF, Schmidt MH. Frailty Indexes in Metastatic Spine Tumor Surgery: A Narrative Review. World Neurosurg 2023; 178:117-122. [PMID: 37499751 DOI: 10.1016/j.wneu.2023.07.095] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 07/19/2023] [Indexed: 07/29/2023]
Abstract
Quantification of preoperative frailty is an important prognostic tool in neurosurgical decision making. Metastatic spine tumor patients undergoing surgery are frail and have unfavorable outcomes that include an increased length of stay, unfavorable discharge disposition, and increased readmission rates. These undesirable outcomes result in higher treatment costs. A heterogeneous mixture of various frailty indexes is available with marked variance in their validation, leading to disparate clinical utility. The lack of a universally accepted definition for frailty, let alone in the method of creation or elements required in the formation of a frailty index, has resulted in a body of frailty literature lacking precision for predicting neurosurgical outcomes. In this review, we examine the role of reported frailty indexes in predicting postoperative outcomes after resection of metastatic spine tumors and aim to assist as a frailty guide for helping clinical decision making.
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Affiliation(s)
- Joanna M Roy
- Topiwala National Medical College, Mumbai, India; Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico, USA.
| | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico, USA; Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Kavelin Rumalla
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico, USA; Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Michael M Covell
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico, USA; School of Medicine, Georgetown University, Seattle, Washington DC, USA
| | - Syed Faraz Kazim
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico, USA; Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Meic H Schmidt
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico, USA; Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
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Covell MM, Bowers C, Kazim SF, Varela S, Rumalla K, Schmidt MH, Bowers CA. Baseline labs predict adverse postoperative outcomes following metastatic brain tumor resection: Analysis of 5943 patients from a prospective surgical registry (2015-2019). Eur J Surg Oncol 2023; 49:107044. [PMID: 37659341 DOI: 10.1016/j.ejso.2023.107044] [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: 05/03/2023] [Revised: 08/04/2023] [Accepted: 08/20/2023] [Indexed: 09/04/2023]
Abstract
INTRODUCTION The present study sought to evaluate the predictive accuracy of preoperative lab values (PLV) on postoperative metastatic brain tumor resection (MBTR) outcomes using data queried from a large prospective international surgical registry, representing over 700 hospitals in 11 countries. METHODS Adult metastatic brain tumor patients (N = 5943) were queried from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database, from 2015 to 2019, using diagnostic and procedural coding. The relationship between preoperative lab values and key indicators of adverse postoperative outcomes following metastatic brain tumor resection were assessed with univariate and multivariate analyses. Adverse postoperative outcomes of interest included: 30-day mortality, Clavien-Dindo Grade IV (CDIV) complications, extended length of stay (eLOS), and discharge to non-home destination (NHD), as well as secondary outcomes: non-Clavien-Dindo Grade IV complications, unplanned reoperation, and unplanned readmission. RESULTS Independent PLV most strongly associated with 30-day mortality were hypernatremia, increased serum creatinine, and thrombocytopenia. Significant predictors of CDIV complications were hypoalbuminemia and thrombocytopenia. eLOS was associated with hypoalbuminemia, anemia, and hyponatremia. The strongest independent predictors of NHD were anemia, hyperbilirubinemia, and hypoalbuminemia. CONCLUSION Several pre-operative lab values independently predicted worse outcomes for metastatic brain tumor resection patients. Hypoalbuminemia, thrombocytopenia, and anemia had the strongest association with the study's adverse postoperative outcomes. These baseline lab values may be considered for preoperative risk stratification of metastatic brain tumor patients.
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Affiliation(s)
- Michael M Covell
- School of Medicine, Georgetown University, Washington, D.C., USA
| | - Charles Bowers
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Samantha Varela
- School of Medicine, University of New Mexico (UNM), Albuquerque, NM, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA.
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Covell MM, Warrier A, Rumalla KC, Dehney CM, Bowers CA. RAI-measured frailty predicts non-home discharge following metastatic brain tumor resection: national inpatient sample analysis of 20,185 patients. J Neurooncol 2023; 164:663-670. [PMID: 37787907 DOI: 10.1007/s11060-023-04461-w] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 09/22/2023] [Indexed: 10/04/2023]
Abstract
PURPOSE Preoperative risk stratification for patients undergoing metastatic brain tumor resection (MBTR) is based on established tumor-, patient-, and disease-specific risk factors for outcome prognostication. Frailty, or decreased baseline physiologic reserve, is a demonstrated independent risk factor for adverse outcomes following MBTR. The present study sought to assess the impact of frailty, measured by the Risk Analysis Index (RAI), on MBTR outcomes. METHODS All MBTR were queried from the National Inpatient Sample (NIS) from 2019 to 2020 using diagnosis and procedural codes. The relationship between preoperative RAI frailty score and our primary outcome - non-home discharge (NHD) - and secondary outcomes - complication rates, extended length of stay (eLOS), and mortality - were analyzed via univariate and multivariable analyses. Discriminatory accuracy was tested by computation of concordance statistics in area under the receiver operating characteristic (AUROC) curve analysis. RESULTS There were 20,185 MBTR patients from the NIS database from 2019 to 2020. Each patient's frailty status was stratified by RAI score: 0-20 (robust): 34%, 21-30 (normal): 35.1%, 31-40 (very frail): 13.9%, 41+ (severely frail): 16.8%. Compared to robust patients, severely frail patients demonstrated increased complication rates (12.2% vs. 6.8%, p < 0.001), eLOS (37.6% vs. 13.2%, p < 0.001), NHD (52.0% vs. 20.6%, p < 0.001), and mortality (9.9% vs. 4.1%, p < 0.001). AUROC curve analysis demonstrated good discriminatory accuracy of RAI-measured frailty in predicting NHD after MBTR (C-statistic = 0.67). CONCLUSION Increasing RAI-measured frailty status is significantly associated with increased complication rates, eLOS, NHD, and mortality following MBTR. Preoperative frailty assessment using the RAI may aid in preoperative surgical planning and risk stratification for patient selection.
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Affiliation(s)
- Michael M Covell
- School of Medicine, Georgetown University, Washington, District of Columbia, USA
| | | | - Kranti C Rumalla
- Feinberg School of Medicine, Northwestern University, Evanston, Illinois, USA
| | | | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, Utah, 84070, USA.
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Shu HT, Yang VB, Badin D, Rogers DL, Covell MM, Osgood GM, Shafiq B. What Factors Are Associated With Delayed Wound Closure in Open Reduction and Internal Fixation of Adult Both-bone Forearm Fractures? Clin Orthop Relat Res 2023; 481:1388-1395. [PMID: 36722772 PMCID: PMC10263215 DOI: 10.1097/corr.0000000000002543] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Received: 08/15/2022] [Accepted: 12/06/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Delayed wound closure is often used after open reduction and internal fixation (ORIF) of both-bone forearm fractures to reduce the risk of skin necrosis and subsequent infection caused by excessive swelling. However, no studies we are aware of have evaluated factors associated with the use of delayed wound closure after ORIF. QUESTIONS/PURPOSES (1) What proportion of patients undergo delayed wound closure after ORIF of adult both-bone forearm fractures? (2) What factors are associated with delayed wound closure? METHODS The medical records of all patients who underwent ORIF with plate fixation for both-bone fractures by the adult orthopaedic trauma service at our institution were considered potentially eligible for analysis. Between January 2010 and April 2022, we treated 74 patients with ORIF for both-bone forearm fractures. Patients were excluded if they had fractures that were fixed more than 2 weeks from injury (six patients), if their fracture was treated with an intramedullary nail (one patient), or if the patient experienced compartment syndrome preoperatively (one patient). No patients with Gustilo-Anderson Type IIIB and C open fractures were included. Based on these criteria, 89% (66 of 74) of the patients were eligible. No further patients were excluded for loss of follow-up because the primary endpoint was the use of delayed wound closure, which was performed at the time of ORIF. However, one further patient was excluded for having bilateral forearm fractures to ensure that each patient had a single fracture for statistical analysis. Thus, 88% (65 of 74) of patients were included in the analysis. These patients were captured by an electronic medical record search of CPT code 25575. The mean ± SD age was 34 ± 15 years and mean BMI was 28 ± 7 kg/m 2 . The mean follow-up duration was 4 ± 5 months. The primary endpoint was the use of delayed wound closure, which was determined at the time of definitive fixation if tension-free closure could not be achieved. All surgeons used a volar Henry or modified Henry approach and a dorsal subcutaneous approach to the ulna for ORIF. Univariate logistic regression was used to identify which factors might be associated with delayed wound closure. A multivariable logistic regression analysis was then performed for male gender, open fractures, age, and BMI. RESULTS Twenty percent (13 of 65) of patients underwent delayed wound closure, 18% (12 of 65) of which occurred in patients who had high-energy injuries and 14% (nine of 65) in patients who had open fractures. Being a man (adjusted odds ratio 9.9 [95% confidence interval 1 to 87]; p = 0.04) was independently associated with delayed wound closure, after adjusting for open fractures, age, and BMI. CONCLUSION One of five patients had delayed wound closure after ORIF of both-bone forearm fractures. Being a man was independently associated with greater odds of delayed wound closure. Surgeons should counsel all patients with these fractures about the possibility of delayed wound closure, with particular attention to men with high-energy and open fractures. Future larger-scale studies are necessary to confirm which factors are associated with the use of delayed wound closure in ORIF of both-bone fractures and its effects on fracture healing. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Henry T. Shu
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Victor B. Yang
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Daniel Badin
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Davis L. Rogers
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Greg M. Osgood
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Babar Shafiq
- Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
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Venkatesh P, Barrie U, Covell MM, Tissot MIJ, Bah MG, Detchou D, Aoun SG, Bagley CA. Alexa Irene Canady: First Female African American Neurosurgeon of the United States. World Neurosurg 2023:S1878-8750(23)00749-0. [PMID: 37270094 DOI: 10.1016/j.wneu.2023.05.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/26/2023] [Accepted: 05/27/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND This historical account reviews the course and lasting impact of Dr. Alexa Irene Canady in neurosurgery. METHODS The writing of this project was sparked by the discovery of original scientific and bibliographical information about Alexa Canady, the first female African-American neurosurgeon in the nation. This article is a thorough review of the literature and information on Canady, reflecting the breadth of these previous publications, and showcasing our viewpoints after comprehensive compilation of information. RESULTS Our paper begins by introducing Dr. Alexa Irene Canady and her decision to pursue a career in medicine during her years in university; follows her journey through medical school and growing interests in neurosurgery; outlines her journey in residency; discusses her career as an established pediatric neurosurgeon at the University of Michigan; outlines her role in establishing a department of pediatric neurosurgery in Pensacola, Florida; and details the obstacles and challenges she faced throughout her career, as well as the barriers she broke along the way. CONCLUSIONS Our article provides glimpses into the personal life and achievements of Dr. Alexa Irene Canady and her marked impact on the field of neurosurgery.
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Affiliation(s)
- Pooja Venkatesh
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Umaru Barrie
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Michael M Covell
- Department of Neurosurgery, Georgetown University, Washington, DC, USA
| | - Marianne I J Tissot
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA; Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Momodou G Bah
- Department of Neurosurgery, Michigan State University College of Human Medicine, East Lansing, MI, USA
| | - Donald Detchou
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA; Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Salah G Aoun
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Carlos A Bagley
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Covell MM, Skandalakis GP, Rumalla K, Schmidt MH, Bowers CA. Letter to the Editor. Hospital Frailty Risk Score and outcome predictions. J Neurosurg 2023; 139:917-918. [PMID: 37243556 DOI: 10.3171/2023.4.jns23293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Vivanco-Suarez J, Salem MM, Sioutas GS, Covell MM, Jankowitz BT, Srinivasan VM, Burkhardt JK. Safety and efficacy of the p48 MW and p64 flow modulation devices: a systematic review and meta-analysis. Neurosurg Focus 2023; 54:E7. [PMID: 37127026 DOI: 10.3171/2023.2.focus22648] [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: 01/01/2023] [Accepted: 02/05/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Flow diverters (FDs) have demonstrated increasing safety and efficacy in treating various types of intracranial aneurysms. Although the underlying mechanism of action of all FDs is similar, differences are noted in their intrinsic characteristics, materials, and deployment techniques. The p64 flow modulation device (p64) and the newer p48 movable wire flow modulation device (p48 MW) are not yet available in the US but have been increasingly used mainly in Europe, demonstrating optimistic results. The authors performed a systematic review and meta-analysis of the literature to evaluate the safety and efficacy of the p64 and p48 MW FDs. METHODS A literature review (between January 1960 and November 2022) of the PubMed, Scopus, Embase, Web of Science, and Cochrane Central Register of Controlled Trials databases was conducted. The primary efficacy outcome was the proportion of complete angiographic occlusion at last follow-up. Complete occlusion was defined as Raymond-Roy class 1 and O'Kelly-Marotta grade D. The primary safety outcomes were the composite safety rate of ischemic and hemorrhagic events (intra- and postprocedure) and the all-cause mortality rate. Data were analyzed using a random-effects proportions meta-analysis, and statistical heterogeneity was assessed. RESULTS Twenty studies with 1781 patients harboring 1957 aneurysms were included in the analysis. Seventeen studies were conducted in Europe. Sixteen studies evaluated the performance of the p64 (MW). Patient ages ranged between 20 and 89 years, and most were female (78.7%). Aneurysm size ranged between 1 and 50 mm. Most aneurysms were unruptured (92.8%) and in the anterior circulation (93.1%). Single antiplatelet therapy pre- and postprocedure was used in 2 studies. Follow-up ranged from 2 to 14.5 months. For the p64 and p48 MW, complete angiographic occlusion rates were 77% (95% CI 68%-85%) and 67% (95% CI 49%-81%), adjunctive coil usage rates were 7% (95% CI 4%-12%) and 4% (95% CI 0%-24%), primary safety composite rates were 2% (95% CI 1%-4%) and 3% (95% CI 1%-11%), and mortality rates were 0.49% (95% CI 0%-1%) and 2% (95% CI 1%-6%), respectively. CONCLUSIONS The p64 and p48 MW have primarily been used in Europe thus far. This analysis found that both devices have an acceptable efficacy and favorable safety profile. However, further studies are needed to evaluate the efficacy and safety of prescribing a single antiplatelet regimen after implantation of the newer-generation FDs with antithrombotic coating surface modification.
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Affiliation(s)
- Juan Vivanco-Suarez
- 1Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania; and
| | - Mohamed M Salem
- 1Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania; and
| | - Georgios S Sioutas
- 1Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania; and
| | | | - Brian T Jankowitz
- 1Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania; and
| | - Visish M Srinivasan
- 1Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania; and
| | - Jan-Karl Burkhardt
- 1Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania; and
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Covell MM, Rumalla K, Kassicieh AJ, Segura AC, Kazim SF, Schmidt MH, Bowers CA. Frailty measured by risk analysis index and adverse discharge outcomes after adult spine deformity surgery: analysis of 3104 patients from a prospective surgical registry (2011-2020). Spine J 2022; 23:739-745. [PMID: 36572283 DOI: 10.1016/j.spinee.2022.12.014] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 12/15/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND CONTEXT Measurement of frailty with the Risk Analysis Index (RAI) has demonstrated improved outcome prediction compared to other frailty indices across the surgical literature. However, the generalizability and clinical utility of preoperative RAI scoring for prediction of postoperative morbidity after adult spinal deformity surgery is presently unknown. Thus, recent studies have called for an RAI analysis of spine deformity outcomes. PURPOSE The present study sought to evaluate the discriminatory accuracy of preoperative frailty, as measured by RAI, for predicting postoperative morbidity among adult spine deformity surgery patients using data queried from a large prospective surgical registry representing over 700 hospitals from 49 US states and 11 countries. STUDY DESIGN/SETTING Secondary analysis of a prospective surgical registry. PATIENT SAMPLE American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2011-2020). OUTCOME MEASURES The primary endpoint was "adverse discharge outcome" (ADO) defined as discharge to a non-home, non-rehabilitation nursing/chronic care facility. METHODS Adult spine deformity surgeries were queried from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2011-2020) using diagnosis and procedure codes. The relationship between increasing preoperative RAI frailty score and increasing rate of primary endpoint (ADO) was assessed with Cochran-Armitage linear trend tests. Discriminatory accuracy was tested by computation of concordance statistics (with 95% confidence interval [CI]) in receiver operating characteristic (ROC) curve analysis. RESULTS A total of 3,104 patients underwent spine deformity surgery and were stratified by RAI score: 0-10: 22%, 11-15: 11%, 16-20: 29%, 21-25: 26%, 26-30: 8.0%, 31-35: 2.4%, and 36+: 1.4%. The rate of ADO was 14% (N=439/3094). The rate of ADO increased significantly with increasing RAI score (p<.0001). RAI demonstrated robust discriminatory accuracy for prediction of ADO in ROC analysis (C-statistic: 0.71, 95% CI: 0.69-0.74, p<.001). In pairwise comparison of ROC curves (DeLong test), RAI demonstrates superior discriminatory accuracy compared to the 5-factor modified frailty index (mFI-5; p<.001). CONCLUSION Preoperative frailty, as measured by RAI, is a robust predictor of postoperative morbidity (measured by ADO) after adult spine deformity surgery. The frailty score may be translated directly to the bedside with a user-friendly risk calculator, deployed here: https://nsgyfrailtyoutcomeslab.shinyapps.io/spineDeformity.
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Affiliation(s)
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA; Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
| | - Alexander J Kassicieh
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA; Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
| | - Aaron C Segura
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA; Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA; Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA; Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA; Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA.
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Covell MM, Hearshen DO, Carson PL, Chenevert TP, Shreve P, Aisen AM, Bookstein FL, Murphy BW, Martel W. Automated analysis of multiple performance characteristics in magnetic resonance imaging systems. Med Phys 1986; 13:815-23. [PMID: 3796477 DOI: 10.1118/1.595804] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
As with other digital imaging systems in heavy medical use, it is desirable with magnetic resonance imaging (MRI) to obtain extensive, rigorous system performance measures from a small set of images of one or two relatively simple test objects. Digital analysis of the parallel square rod (PSR) test object introduces digital image system self-evaluation to MRI and extends automated image evaluation to include rigorous measures throughout the imaging volume rather than just average measures over the image. Precise comparisons with theory and between systems can be performed as well as quality control and corrections for nonuniformities. The PSR test object consists of an 18 X 18 X 36 cm rectangular acrylic container enclosing 60 parallel square acrylic rods running the entire length. The inter-rod space is filled with a liquid or gel that produces strong, tissuelike signals in MRI and high contrast relative to the rods for computed tomography (CT). For profiles of slice thickness and separation, the rods are tilted in the test object to intersect the image plane at a 45 degree angle when the test object sides are parallel and perpendicular to the image plane. The test object itself is rotated 6-12 degrees about its major axis so that the sides of the rods make a small angle to the rows and columns of pixels. This allows digital sampling at finer spacing than the pixels for determination of edge response functions.(ABSTRACT TRUNCATED AT 250 WORDS)
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