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  • Author or Editor: Lonni R. Schultz x
  • Journal of Neurosurgery x
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Panayiotis N. Varelas, Lotfi Hacein-Bey, Lonni Schultz, Mary Conti, Marianna V. Spanaki and Thomas A. Gennarelli

Object

The aim of this study was to examine the variables influencing the mode and location of death in patients admitted to a neurosurgical intensive care unit (NICU), including the participation of a newly appointed neurointensivist (NI).

Methods

Data from all patients admitted to a university hospital NICU were prospectively collected and compared between 2 consecutive 19-month periods before and after the appointment of an NI.

Results

One thousand eighty-seven patients were admitted before and 1279 after the NI's appointment. The withdrawal of life support (WOLS) occurred in 52% of all cases of death. Death following WOLS compared with survival was independently associated with an older patient age (OR 1.04/year, 95% CI 1.03–1.05), a higher University Hospitals Consortium (UHC) expected mortality rate (OR 1.05/%, 95% CI 1.04–1.07), transfer from another hospital (OR 3.7, 95% CI 1.6–8.4) or admission through the emergency department (OR 5.3, 95% CI 2.4–12), admission to the neurosurgery service (OR 7.5, 95% CI 3.2–17.6), and diagnosis of an ischemic stroke (OR 5.4, 95% CI 1.4–20.8) or intracerebral hemorrhage (OR 5.7, 95% CI 1.9–16.7). On discharge from the NICU, 54 patients died on the hospital ward (2.7% mortality rate). A younger patient age (OR 0.94/year, 95% CI 0.92–0.96), higher UHC-expected mortality rate (OR 1.01/%, 95% CI 1–1.03), and admission to the neurosurgery service (OR 9.35, 95% CI 1.83–47.7) were associated with death in the NICU rather than the ward. There was no association between the participation of an NI and WOLS or ward mortality rate.

Conclusions

The mode and location of death in NICU-admitted patients did not change after the appointment of an NI. Factors other than the participation of an NI—including patient age and the severity and type of neurological injury—play a significant role in the decision to withdraw life support in the NICU or dying in-hospital after discharge from the NICU.

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Jessin K. John, Adam M. Robin, Aqueel H. Pabaney, Richard A. Rammo, Lonni R. Schultz, Neema S. Sadry and Ian Y. Lee

OBJECTIVE

Recent studies have demonstrated that periventricular tumor location is associated with poorer survival and that tumor location near the ventricle limits the extent of resection. This finding may relate to the perception that ventricular entry leads to further complications and thus surgeons may choose to perform less aggressive resection in these areas. However, there is little support for this view in the literature. This study seeks to determine whether ventricular entry is associated with more complications during craniotomy for brain tumor resection.

METHODS

A retrospective analysis of patients who underwent craniotomy for tumor resection at Henry Ford Hospital between January 2010 and November 2012 was conducted. A total of 183 cases were reviewed with attention to operative entry into the ventricular system, postoperative use of an external ventricular drain (EVD), subdural hematoma, hydrocephalus, and symptomatic intraventricular hemorrhage (IVH).

RESULTS

Patients in whom the ventricles were entered had significantly higher rates of any complication (46% vs 21%). Complications included development of subdural hygroma, subdural hematoma, intraventricular hemorrhage, subgaleal collection, wound infection, urinary tract infection/deep venous thrombosis, hydrocephalus, and ventriculoperitoneal (VP) shunt placement. Specifically, these patients had significantly higher rates of EVD placement (23% vs 1%, p < 0.001), hydrocephalus (6% vs 0%, p = 0.03), IVH (14% vs 0%, p < 0.001), infection (15% vs 5%, p = 0.04), and subgaleal collection (20% vs 4%, p < 0.001). It was also observed that VP shunt placement was only seen in cases of ventricular entry (11% vs 0%, p = 0.001) with 3 of 4 of these patients having a large ventricular entry (defined here as entry greater than a pinhole [< 3 mm] entry). Furthermore, in a subset of glioblastoma patients with and without ventricular entry, Kaplan-Meier estimates for survival demonstrated a median survival time of 329 days for ventricular entry compared with 522 days for patients with no ventricular entry (HR 1.13, 95% CI 0.65–1.96; p = 0.67).

CONCLUSIONS

There are more complications associated with ventricular entry during brain tumor resection than in nonviolated ventricular systems. Better strategies for management of periventricular tumor resection should be actively sought to improve resection and survival for these patients.

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Kevin Reinard, David R. Nerenz, Azam Basheer, Rizwan Tahir, Timothy Jelsema, Lonni Schultz, Ghaus Malik, Ellen L. Air and Jason M. Schwalb

OBJECTIVE

A number of studies have documented inequalities in care and outcomes for a variety of clinical conditions. The authors sought to identify racial and socioeconomic disparities in the diagnosis and treatment of trigeminal neuralgia (TN), as well as the potential underlying reasons for those disparities, which could serve as areas of focus for future quality improvement initiatives.

METHODS

The medical records of patients with an ICD-9 code of 350.1, signifying a diagnosis of TN, at the Henry Ford Medical Group (HFMG) in the period from 2006 to 2012 were searched, and clinical and socioeconomic data were retrospectively reviewed. Analyses were conducted to assess potential racial differences in subspecialty referral patterns and the specific type of treatment modality undertaken for patients with TN.

RESULTS

The authors identified 652 patients eligible for analysis. Compared with white patients, black patients were less likely to undergo percutaneous ablative procedures, stereotactic radiosurgery, or microvascular decompression (p < 0.001). However, there was no difference in the likelihood of blacks and whites undergoing a procedure once they had seen a neurosurgeon (67% vs 70%, respectively; p = 0.712). Blacks and whites were equally likely to be seen by a neurologist or neurosurgeon if they were initially seen in either the emergency room (38% vs 37%, p = 0.879) or internal medicine (48% vs 50%, p = 0.806). Among patients diagnosed (268 patients) after the 2008 publication of the European Federation of Neurological Societies and the American Academy of Neurology guidelines for medical therapy for TN, fewer than 50% were on medications sanctioned by the guidelines, and there were no statistically significant racial disparities between white and black patients (p = 0.060).

CONCLUSIONS

According to data from a large database from one of the nation's largest comprehensive health care systems, there were significant racial disparities in the likelihood of a patient undergoing a procedure for TN. This appeared to stem from outside HFMG from a difference in referral patterns to the neurologists and neurosurgeons.