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Hansen Deng, John K. Yue, Ethan A. Winkler, Sanjay S. Dhall, Geoffrey T. Manley and Phiroz E. Tarapore

OBJECTIVE

Pediatric firearm injury is a leading cause of death and disability in the youth of the United States. The epidemiology of and outcomes following gunshot wounds to the head (GSWHs) are in need of systematic characterization. Here, the authors analyzed pediatric GSWHs from a population-based sample to identify predictors of prolonged hospitalization, morbidity, and death.

METHODS

All patients younger than 18 years of age and diagnosed with a GSWH in the National Sample Program (NSP) of the National Trauma Data Bank (NTDB) in 2003–2012 were eligible for inclusion in this study. Variables of interest included injury intent, firearm type, site of incident, age, sex, race, health insurance, geographic region, trauma center level, isolated traumatic brain injury (TBI), hypotension in the emergency department, Glasgow Coma Scale (GCS) score, and Injury Severity Score (ISS). Risk predictors for a prolonged hospital stay, morbidity, and mortality were identified. Odds ratios, mean increases or decreases (B), and 95% confidence intervals were reported. Statistical significance was assessed at α < 0.001 accounting for multiple comparisons.

RESULTS

In a weighted sample of 2847 pediatric patients with GSWHs, the mean age was 14.8 ± 3.3 years, 79.2% were male, and 59.0% had severe TBI (GCS score 3–8). The mechanism of assault (63.0%), the handgun as firearm (45.6%), and an injury incurred in a residential area (40.6%) were most common. The mean hospital length of stay was 11.6 ± 14.4 days for the survivors, for whom suicide injuries involved longer hospitalizations (B = 5.9-day increase, 95% CI 3.3–8.6, p < 0.001) relative to those for accidental injuries. Mortality was 45.1% overall but was greater with injury due to suicidal intent (mortality 71.5%, p < 0.001) or caused by a shotgun (mortality 56.5%, p < 0.001). Lower GCS scores, higher ISSs, and emergency room hypotension predicted poorer outcomes. Patients with private insurance had lower mortality odds than those with Medicare/Medicaid (OR 2.4, 95% CI 1.7–3.4, p < 0.001) or government insurance (OR 3.6, 95% CI 2.2–5.8, p < 0.001). Management at level II centers, compared to level I, was associated with lower odds of returning home (OR 0.3, 95% CI 0.2–0.5, p < 0.001).

CONCLUSIONS

From 2003 to 2012, with regard to pediatric TBI hospitalizations due to GSWHs, their proportion remained stable, those caused by accidental injuries decreased, and those attributable to suicide increased. Overall mortality was 45%. Hypotension, cranial and overall injury severity, and suicidal intent were associated with poor prognoses. Patients treated at level II trauma centers had lower odds of being discharged home. Given the spectrum of risk factors that predispose children to GSWHs, emphasis on screening, parental education, and standardization of critical care management is needed to improve outcomes.

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Ethan A. Winkler, John K. Yue, Hansen Deng, Kunal P. Raygor, Ryan R. L. Phelps, Caleb Rutledge, Alex Y. Lu, Roberto Rodriguez Rubio, Jan-Karl Burkhardt and Adib A. Abla

OBJECTIVE

Cerebral bypass procedures are microsurgical techniques to augment or restore cerebral blood flow when treating a number of brain vascular diseases including moyamoya disease, occlusive vascular disease, and cerebral aneurysms. With advances in endovascular therapy and evolving evidence-based guidelines, it has been suggested that cerebral bypass procedures are in a state of decline. Here, the authors characterize the national trends in cerebral bypass surgery in the United States from 2002 to 2014.

METHODS

Using the National (Nationwide) Inpatient Sample, the authors extracted for analysis the data on all adult patients who had undergone cerebral bypass as indicated by ICD-9-CM procedure code 34.28. Indications for bypass procedures, patient demographics, healthcare costs, and regional variations are described. Results were stratified by indication for cerebral bypass including moyamoya disease, occlusive vascular disease, and cerebral aneurysms. Predictors of inpatient complications and death were evaluated using multivariable logistic regression analysis.

RESULTS

From 2002 to 2014, there was an increase in the annual number of cerebral bypass surgeries performed in the United States. This increase reflected a growth in the number of cerebral bypass procedures performed for adult moyamoya disease, whereas cases performed for occlusive vascular disease or cerebral aneurysms declined. Inpatient complication rates for cerebral bypass performed for moyamoya disease, vascular occlusive disease, and cerebral aneurysm were 13.2%, 25.1%, and 56.3%, respectively. Rates of iatrogenic stroke ranged from 3.8% to 20.4%, and mortality rates were 0.3%, 1.4%, and 7.8% for moyamoya disease, occlusive vascular disease, and cerebral aneurysms, respectively. Multivariate logistic regression confirmed that cerebral bypass for vascular occlusive disease or cerebral aneurysm is a statistically significant predictor of inpatient complications and death. Mean healthcare costs of cerebral bypass remained unchanged from 2002 to 20014 and varied with treatment indication: moyamoya disease $38,406 ± $483, vascular occlusive disease $46,618 ± $774, and aneurysm $111,753 ± $2381.

CONCLUSIONS

The number of cerebral bypass surgeries performed for adult revascularization has increased in the United States from 2002 to 2014. Rising rates of surgical bypass reflect a greater proportion of surgeries performed for moyamoya disease, whereas bypasses performed for vascular occlusive disease and aneurysms are decreasing. Despite evolving indications, cerebral bypass remains an important surgical tool in the modern endovascular era and may be increasing in use. Stagnant complication rates highlight the need for continued interest in advancing available bypass techniques or technologies to improve patient outcomes.

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John K. Yue, Ethan A. Winkler, Jonathan W. Rick, Hansen Deng, Carlene P. Partow, Pavan S. Upadhyayula, Harjus S. Birk, Andrew K. Chan and Sanjay S. Dhall

Traumatic spinal cord injury (SCI) often occurs in patients with concurrent traumatic injuries in other body systems. These patients with polytrauma pose unique challenges to clinicians. The current review evaluates existing guidelines and updates the evidence for prehospital transport, immobilization, initial resuscitation, critical care, hemodynamic stability, diagnostic imaging, surgical techniques, and timing appropriate for the patient with SCI who has multisystem trauma. Initial management should be systematic, with focus on spinal immobilization, timely transport, and optimizing perfusion to the spinal cord. There is general evidence for the maintenance of mean arterial pressure of > 85 mm Hg during immediate and acute care to optimize neurological outcome; however, the selection of vasopressor type and duration should be judicious, with considerations for level of injury and risks of increased cardiogenic complications in the elderly. Level II recommendations exist for early decompression, and additional time points of neurological assessment within the first 24 hours and during acute care are warranted to determine the temporality of benefits attributable to early surgery. Venous thromboembolism prophylaxis using low-molecular-weight heparin is recommended by current guidelines for SCI. For these patients, titration of tidal volumes is important to balance the association of earlier weaning off the ventilator, with its risk of atelectasis, against the risk for lung damage from mechanical overinflation that can occur with prolonged ventilation. Careful evaluation of infection risk is a priority following multisystem trauma for patients with relative immunosuppression or compromise. Although patients with polytrauma may experience longer rehabilitation courses, long-term neurological recovery is generally comparable to that in patients with isolated SCI after controlling for demographics. Bowel and bladder disorders are common following SCI, significantly reduce quality of life, and constitute a focus of targeted therapies. Emerging biomarkers including glial fibrillary acidic protein, S100β, and microRNAs for traumatic SCIs are presented. Systematic management approaches to minimize sources of secondary injury are discussed, and areas requiring further research, implementation, and validation are identified.

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Hansen Deng, Andrew K. Chan, Simon G. Ammanuel, Alvin Y. Chan, Taemin Oh, Henry C. Skrehot, Caleb S. Edwards, Sravani Kondapavulur, Amy D. Nichols, Catherine Liu, John K. Yue, Sanjay S. Dhall, Aaron J. Clark, Dean Chou, Christopher P. Ames and Praveen V. Mummaneni

OBJECTIVE

Surgical site infection (SSI) following spine surgery causes major morbidity and greatly impedes functional recovery. In the modern era of advanced operative techniques and improved perioperative care, SSI remains a problematic complication that may be reduced with institutional practices. The objectives of this study were to 1) characterize the SSI rate and microbial etiology following spine surgery for various thoracolumbar diseases, and 2) identify risk factors that were associated with SSI despite current perioperative management.

METHODS

All patients treated with thoracic or lumbar spine operations on the neurosurgery service at the University of California, San Francisco from April 2012 to April 2016 were formally reviewed for SSI using the National Healthcare Safety Network (NHSN) guidelines. Preoperative risk variables included age, sex, BMI, smoking, diabetes mellitus (DM), coronary artery disease (CAD), ambulatory status, history of malignancy, use of preoperative chlorhexidine gluconate (CHG) showers, and the American Society of Anesthesiologists (ASA) classification. Operative variables included surgical pathology, resident involvement, spine level and surgical technique, instrumentation, antibiotic and steroid use, estimated blood loss (EBL), and operative time. Multivariable logistic regression was used to evaluate predictors for SSI. Odds ratios and 95% confidence intervals were reported.

RESULTS

In total, 2252 consecutive patients underwent thoracolumbar spine surgery. The mean patient age was 58.6 ± 13.8 years and 49.6% were male. The mean hospital length of stay was 6.6 ± 7.4 days. Sixty percent of patients had degenerative conditions, and 51.9% underwent fusions. Sixty percent of patients utilized presurgery CHG showers. The mean operative duration was 3.7 ± 2 hours, and the mean EBL was 467 ± 829 ml. Compared to nonfusion patients, fusion patients were older (mean 60.1 ± 12.7 vs 57.1 ± 14.7 years, p < 0.001), were more likely to have an ASA classification > II (48.0% vs 36.0%, p < 0.001), and experienced longer operative times (252.3 ± 120.9 minutes vs 191.1 ± 110.2 minutes, p < 0.001). Eleven patients had deep SSI (0.49%), and the most common causative organisms were methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus. Patients with CAD (p = 0.003) or DM (p = 0.050), and those who were male (p = 0.006), were predictors of increased odds of SSI, and presurgery CHG showers (p = 0.001) were associated with decreased odds of SSI.

CONCLUSIONS

This institutional experience over a 4-year period revealed that the overall rate of SSI by the NHSN criteria was low at 0.49% following thoracolumbar surgery. This was attributable to the implementation of presurgery optimization, and intraoperative and postoperative measures to prevent SSI across the authors’ institution. Despite prevention measures, having a history of CAD or DM, and being male, were risk factors associated with increased SSI, and presurgery CHG shower utilization decreased SSI risk in patients.