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Daniel A. Donoho, Timothy Wen, Jonathan Liu, Hosniya Zarabi, Eisha Christian, Steven Cen, Gabriel Zada, J. Gordon McComb, Mark D. Krieger, William J. Mack and Frank J. Attenello

OBJECTIVE

Although current pediatric neurosurgery guidelines encourage the treatment of pediatric malignant brain tumors at specialized centers such as pediatric hospitals, there are limited data in support of this recommendation. Previous studies suggest that children treated by higher-volume surgeons and higher-volume hospitals may have better outcomes, but the effect of treatment at dedicated children’s hospitals has not been investigated.

METHODS

The authors analyzed the Healthcare Cost and Utilization Project Kids’ Inpatient Database (KID) from 2000–2009 and included all patients undergoing a craniotomy for malignant pediatric brain tumors based on ICD-9-CM codes. They investigated the effects of patient demographics, tumor location, admission type, and hospital factors on rates of routine discharge and mortality.

RESULTS

From 2000 through 2009, 83.6% of patients had routine discharges, and the in-hospital mortality rate was 1.3%. In multivariate analysis, compared with children treated at an institution designated as a pediatric hospital by NACHRI (National Association of Children’s Hospitals and Related Institutions), children receiving treatment at a pediatric unit within an adult hospital (OR 0.5, p < 0.01) or a general hospital without a designated pediatric unit (OR 0.4, p < 0.01) were less likely to have routine discharges. Treatment at a large hospital (> 400 beds; OR 1.8, p = 0.02) and treatment at a teaching hospital (OR 1.7, p = 0.02) were independently associated with greater likelihood of routine discharge. However, patients transferred between facilities had a significantly decreased likelihood of routine discharge (OR 0.5, p < 0.01) and an increased likelihood of mortality (OR 5.0, p < 0.01). Procedural volume was not associated with rate of routine discharge or mortality.

CONCLUSIONS

These findings may have implications for planning systems of care for pediatric patients with malignant brain tumors. The authors hope to motivate future research into the specific factors that may lead to improved outcomes at designated pediatric hospitals.

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Eisha A. Christian, Edward F. Melamed, Edwin Peck, Mark D. Krieger and J. Gordon McComb

OBJECT

Posthemorrhagic hydrocephalus (PHH) in the preterm infant remains a major neurological complication of prematurity. The authors first described insertion of a specially designed low-profile subcutaneous ventricular catheter reservoir for temporary management of hydrocephalus in 1983. This report presents the follow-up experience with the surgical management of PHH in this population and describes outcomes both in infants who were stable for permanent shunt insertion and those initially temporized with a ventricular reservoir (VR) prior to permanent ventriculoperitoneal (VP)/ventriculoatrial (VA) shunt placement.

METHODS

A retrospective review was undertaken of the medical records of all premature infants surgically treated for posthemorrhagic hydrocephalus (PHH) between 1997 and 2012 at Children’s Hospital Los Angeles.

RESULTS

Over 14 years, 91 preterm infants with PHH were identified. Fifty neonates received temporizing measures via a VR that was serially tapped for varying time periods. For the remaining 41 premature infants, VP/VA shunt placement was the first procedure. Patients with a temporizing measure as their initial procedure had undergone CSF diversion significantly earlier in life than those who had permanent shunting as the initial procedure (29 vs 56 days after birth, p < 0.01). Of the infants with a VR as their initial procedure, 5/50 (10%) did not undergo subsequent VP/VA shunt placement. The number of shunt revisions and the rates of loculated hydrocephalus and shunt infection did not statistically differ between the 2 groups.

CONCLUSIONS

Patients with initial VR insertion as a temporizing measure received a CSF diversion procedure significantly earlier than those who received a permanent shunt as their initial procedure. Otherwise, the outcomes with regard to shunt revisions, loculated hydrocephalus, and shunt infection were not different for the 2 groups.

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Eisha A. Christian, Diana L. Jin, Frank Attenello, Timothy Wen, Steven Cen, William J. Mack, Mark D. Krieger and J. Gordon McComb

OBJECT

Even with improved prenatal and neonatal care, intraventricular hemorrhage (IVH) occurs in approximately 25%–30% of preterm infants, with a subset of these patients developing hydrocephalus. This study was undertaken to describe current trends in hospitalization of preterm infants with posthemorrhagic hydrocephalus (PHH) using the Nationwide Inpatient Sample (NIS) and the Kids’ Inpatient Database (KID).

METHODS

The KID and NIS were combined to generate data for the years 2000–2010. All neonatal discharges with ICD-9-CM codes for preterm birth with IVH alone or with IVH and hydrocephalus were included.

RESULTS

There were 147,823 preterm neonates with IVH, and 9% of this group developed hydrocephalus during the same admission. Of patients with Grade 3 and 4 IVH, 25% and 28%, respectively, developed hydrocephalus in comparison with 1% and 4% of patients with Grade 1 and 2 IVH, respectively. Thirty-eight percent of patients with PHH had permanent ventricular shunts inserted. Mortality rates were 4%, 10%, 18%, and 40%, respectively, for Grade 1, 2, 3, and 4 IVH during initial hospitalization. Length of stay has been trending upward for both groups of IVH (49 days in 2000, 56 days in 2010) and PHH (59 days in 2000, 70 days in 2010). The average hospital cost per patient (adjusted for inflation) has also increased, from $201,578 to $353,554 (for IVH) and $260,077 to $495,697 (for PHH) over 11 years.

CONCLUSIONS

The number of neonates admitted with IVH has increased despite a decrease in the number of preterm births. Rates of hydrocephalus and mortality correlated closely with IVH grade. The incidence of hydrocephalus in preterm infants with IVH remained stable between 8% and 10%. Over an 11-year period, there was a progressive increase in hospital cost and length of stay for preterm neonates with IVH and PHH that may be explained by a concurrent increase in the proportion of patients with congenital cardiac anomalies.

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Frank J. Attenello, Eisha Christian, Timothy Wen, Steven Cen, Gabriel Zada, Erin N. Kiehna, Mark D. Krieger, J. Gordon McComb and William J. Mack

OBJECT

Recently published data have suggested an increase in adverse outcomes in pediatric patients after insertion or revision of a ventricular CSF diversion shunt after a same-day weekend procedure. The authors undertook an evaluation of the impact of weekend admission and time to shunting on surgery-related quality outcomes in pediatric patients who underwent ventricular shunt insertion or revision.

METHODS

Pediatric patients with hydrocephalus who underwent ventriculoperitoneal, ventriculoatrial, or ventriculopleural shunt placement were selected from the 2000–2010 Nationwide Inpatient Sample and Kids’ Inpatient Database. Multivariate regression analyses (adjusted for patient, hospital, case severity, and time to shunting) were used to determine the differences in inpatient mortality and routine discharge rates among patients admitted on a weekday versus those among patients admitted on a weekend.

RESULTS

There were 99,472 pediatric patients with shunted hydrocephalus, 16% of whom were admitted on a weekend. After adjustment for disease severity, time to procedure, and admission acuity, weekend admission was not associated with an increase in the inpatient mortality rate (p = 0.46) or a change in the percentage of routine discharges (p = 0.98) after ventricular shunt procedures. In addition, associations were unchanged after an evaluation of patients who underwent shunt revision surgery. High-volume centers were incidentally noted in multivariate analysis to have increased rates of routine discharge (OR 1.04 [95% CI 1.01–1.07]; p = 0.02).

CONCLUSIONS

Contrary to those of previous studies, the authors’ data suggest that weekend admission is not associated with poorer outcomes for ventricular shunt insertion or revision. Increased rates of routine discharge were noted at high-volume centers.

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Frank J. Attenello, Alvin Ng, Timothy Wen, Steven Y. Cen, Nerses Sanossian, Arun P. Amar, Gabriel Zada, Mark D. Krieger, J. Gordon McComb and William J. Mack

OBJECT

Racial and socioeconomic disparities within the US health care system are a growing concern. Despite extensive research and efforts to narrow such disparities, minorities and economically disadvantaged patients continue to exhibit inferior health care outcomes. Disparities in the delivery of pediatric neurosurgical care are understudied. Authors of this study examine the impact of race and socioeconomic status on outcomes following pediatric CSF shunting procedures.

METHODS

Discharge information from the 2000, 2003, 2006, and 2009 Kids' Inpatient Database for individuals (age < 21 years) with a diagnosis of hydrocephalus who had undergone CSF shunting procedures was abstracted for analysis. Multivariate logistic regression analyses, adjusting for patient and hospital factors and annual CSF shunt procedure volume, were performed to evaluate the effects of race and payer status on the likelihood of inpatient mortality and nonroutine hospital discharge (that is, not to home).

RESULTS

African American patients (p < 0.05) had an increased likelihood of inpatient death and nonroutine discharge compared with white patients. Furthermore, Medicaid patients had a significantly higher likelihood of nonroutine discharge (p < 0.05) as compared with privately insured patients.

CONCLUSIONS

Findings in this study, which utilized US population-level data, suggest the presence of racial and socioeconomic status outcome disparities following pediatric CSF shunting procedures. Further studies on health disparities in this population are warranted.

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Eisha A. Christian, Thomas A. Imahiyerobo, Swathi Nallapa, Mark Urata, J. Gordon McComb and Mark D. Krieger

OBJECT

The authors’ aim was perform a systematic review on the incidence of intracranial hypertension (IH) after surgery for craniosynostosis.

METHODS

A systematic literature review was conducted using PubMed to assess the rate of postoperative IH in studies published between 1985 and 2014. Inclusion criteria were 1) English-language literature; 2) human subjects; 3) pediatric cases; and 4) postoperative IH confirmed with invasive intracranial pressure monitoring.

RESULTS

Seven studies met inclusion criteria. IH was reported to be present in 5% of patients postoperatively with sagittal synostosis and 4% of patients with all forms of nonsyndromic craniosynostosis. Inadequate numbers were available to determine the incidence of postoperative IH for syndromic and individual nonsyndromic sutural synostosis based on the inclusion criteria. Surgical groups were subdivided into cranial remodeling procedures without orbital advancement and craniofacial procedures with orbital advancement. IH was reported to be present in 5% of patients with all forms of nonsyndromic sutural stenosis after cranial remodeling procedures and 1% after craniofacial advancement.

CONCLUSIONS

Postoperative development of elevated intracranial pressure has been described by multiple institutions, but the variation in how IH is determined and the multiple surgical procedures to correct craniosynostosis has limited the number of studies subject to a meta-analysis. Nonetheless, this entity deserves special attention, and further studies are required to determine the true incidence of postoperative IH, including the role of various surgical procedures on its incidence. The long-term consequences of chronic IH in this group of patients also need to be evaluated.

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Stephanie L. Da Silva, Yasser Jeelani, Ha Dang, Mark D. Krieger and J. Gordon McComb

OBJECT

There is a known association of hydrocephalus with encephaloceles. Risk factors for hydrocephalus and neurological deficit were ascertained in a series of patients born with an encephalocele.

METHODS

A retrospective analysis was undertaken of patients treated for encephaloceles at Children's Hospital Los Angeles between 1994 and 2012. The following factors were evaluated for their prognostic value: age at presentation, sex, location of encephalocele, size, contents, microcephaly, presence of hydrocephalus, CSF leak, associated cranial anomalies, and neurological outcome.

RESULTS

Seventy children were identified, including 38 girls and 32 boys. The median age at presentation was 2 months. The mean follow-up duration was 3.7 years. Encephalocele location was classified as anterior (n = 14) or posterior (n = 56) to the coronal suture. The average maximum encephalocele diameter was 4 cm (range 0.5–23 cm). Forty-seven encephaloceles contained neural tissue. Eight infants presented at birth with CSF leaking from the encephalocele, with 1 being infected. Six patients presented with hydrocephalus, while 11 developed progressive hydrocephalus postoperatively. On univariate analysis, the presence of neural tissue, cranial anomalies, encephalocele size of at least 2 cm, seizure disorder, and microcephaly were each positively associated with hydrocephalus. On multivariate logistic regression modeling, the single prognostic factor for hydrocephalus of borderline statistical significance was the presence of neural tissue (odds ratio [OR] = 5.8, 95% confidence interval [CI] = 0.8–74.0). Fourteen patients had severe developmental delay, 28 had mild/moderate delay, and 28 were neurologically normal. On univariate analysis, the presence of cranial anomalies, larger size of encephalocele, hydrocephalus, and microcephaly were positively associated with neurological deficit. In the multivariable model, the only statistically significant prognostic factor for neurological deficit was presence of hydrocephalus (OR 17.2, 95% CI 1.7–infinity).

CONCLUSIONS

In multivariate models, the presence of neural tissue was borderline significantly associated with hydrocephalus and the presence of hydrocephalus was significantly associated with neurological deficit. The location of the encephalocele did not have a statistically significant association with incidence of hydrocephalus or neurological deficit. In contrast to modestly good/fair neurological outcome in children with an encephalocele without hydrocephalus, the presence of hydrocephalus resulted in a far worse neurological outcome.

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Lindsey Spiegelman, Richa Asija, Stephanie L. Da Silva, Mark D. Krieger and J. Gordon McComb

Object

Most CSF-diverting shunt systems have an access port that can be percutaneously tapped. Tapping the shunt can yield valuable information as to its function and whether an infection is present. The fear of causing a shunt infection by tapping may limit the physician's willingness to do so. The authors of this study investigate the risk of infecting a shunt secondary to percutaneous tapping.

Methods

Following institutional review board approval, CSF specimens obtained from tapping an indwelling CSF-diverting shunt during the 2011 and 2012 calendar years were identified and matched with clinical information. A culture-positive CSF sample was defined as an infection. If results were equivocal, such as a broth-only–positive culture, a repeat CSF specimen was examined. The CSF was obtained by tapping the shunt access port with a 25-gauge butterfly needle after prepping the unshaven skin with chlorhexidine.

Results

During the study period, 266 children underwent 542 shunt taps. With 541 taps, no clinical evidence of a subsequent shunt infection was found. One child's CSF went from sterile to infected 11 days later; however, this patient had redness along the shunt tract at the time of the initial sterile tap.

Conclusions

The risk of infection from tapping a shunt is remote if the procedure is done correctly.