Search Results

You are looking at 1 - 10 of 47 items for

  • Author or Editor: Joseph H. Piatt x
  • Refine by Access: all x
Clear All Modify Search
Full access

Joseph H. Piatt Jr.

OBJECT

In the US, race and economic status have pervasive associations with mechanisms of injury, severity of injury, management, and outcomes of trauma. The goal of the current study was to examine these relationships on a large scale in the setting of pediatric spinal injury.

METHODS

Admissions for spinal fracture without or with spinal cord injury (SCI), spinal dislocation, and SCI without radiographic abnormality were identified in the Kids’ Inpatient Database (KID) and the National Trauma Data Bank (NTDB) registry for 2009. Patients ranged in age from birth up to 21 years. Data from the KID were used to estimate nationwide annual incidences. Data from the NTDB were used to describe patterns of injury in relation to age, race, and payor, with corroboration from the KID. Multiple logistic regression was used to model rates of mortality and spinal fusion.

RESULTS

In 2009, the estimated incidence of hospital admission for spinal injury in the US was 170 per 1 million in the population under 21 years of age. The incidence of SCI was 24 per 1 million. Incidences varied regionally. Adolescents predominated. Patterns of injury varied by age, race, and payor. Black patients were more severely injured than patients of other races as measured by Injury Severity Scale scores. Among black patients with spinal injury in the NTDB, 23.9% suffered firearm injuries; only 1% of white patients suffered firearm injuries. The overall mortality rate in the NTDB was 3.9%. In a multivariate analysis that included a large panel of clinical and nonclinical factors, black race retained significance as a predictor of mortality (p = 0.006; adjusted OR 1.571 [1.141–2.163]). Rates of spinal fusion were associated with race and payor in the NTDB data and with payor in the KID: patients with better insurance underwent spinal fusion at higher rates.

CONCLUSIONS

The epidemiology of pediatric spinal injury in the US cannot be understood apart from considerations of race and economic status.

Free access

Joseph H. Piatt Jr.

OBJECTIVE

The natural history and management of myelomeningocele (MM) in children is fairly well understood. There is a deficiency of knowledge regarding the care of adults, however, even though there are now more adults than children living with MM. The purpose of this study was to characterize the hospital care of adults with MM and hydrocephalus on a nationwide population base. Adults with other forms of spina bifida (SB) were studied for contrast.

METHODS

The Nationwide Inpatient Sample for the years 2001, 2004, 2007, and 2010 was queried for admissions with diagnostic ICD-9-CM codes for MM with hydrocephalus and for other forms of SB.

RESULTS

There were 4657 admissions of patients with MM and 12,369 admissions of patients with SB in the sample. Nationwide rates of admission increased steadily for both MM and SB patients throughout the study period. Hospital charges increased faster than the health care component of the Consumer Price Index. Patients with MM were younger than patients with SB, but annual admissions of MM patients older than 40 years increased significantly during the study period. With respect to hospital death and discharge home, outcomes of surgery for hydrocephalus were superior at high-volume hospitals. Patients with MM and SB were admitted to the hospital more frequently than the general population for surgery to treat degenerative spine disease.

CONCLUSIONS

Patients with MM and SB continue to require neurosurgical attention in adulthood, and the demand for services for older patients with MM is increasing. Management of hydrocephalus at high-volume centers is advantageous for this population. Patients with MM or SB may experience high rates of degenerative spine disease.

Full access

Joseph H. Piatt Jr

External hydrocephalus has been associated with subdural hematomas in infancy, and the hematomas have been noted to be secondary to minor trauma or have even been described as spontaneous. The author reports the case of an infant with external hydrocephalus who developed retinal as well as subdural hemorrhages after sustaining a minor head injury. Although retinal hemorrhage in infancy has been considered virtually pathognomonic of child abuse, in the setting of external hydrocephalus a more cautious interpretation may be appropriate.

Restricted access

Joseph H. Piatt Jr.

Object

Cerebrospinal fluid shunts are the mainstay of the treatment of hydrocephalus. In past studies, outcomes of shunt surgery have been analyzed based on follow-up of 1 year or longer. The goal of the current study is to characterize 30-day shunt outcomes, to identify clinical risk factors for shunt infection and failure, and to develop statistical models that might be used for risk stratification.

Methods

Data for 2012 were obtained from the National Surgical Quality Improvement Program-Pediatrics (NSQIP-P) of the American College of Surgeons. Files with index surgical procedures for insertion or revision of a CSF shunt composed the study set. Returns to the operating room within 30 days for shunt infection and for shunt failure without infection were the study end points. Associations with a large number of potential clinical risk factors were analyzed on a univariate basis. Logistic regression was used for multivariate analysis.

Results

There were 1790 index surgical procedures analyzed. The overall rates of shunt infection and shunt failure without infection were 2.0% and 11.5%, respectively. Male sex, steroid use in the preceding 30 days, and nutritional support at the time of surgery were risk factors for shunt infection. Cardiac disease was a risk factor for shunt failure without infection, and initial shunt insertion, admission during the second quarter, and neuromuscular disease appeared to be protective. There was a weak association of increasing age with shunt failure without infection. Models based on these factors accounted for no more than 6% of observed variance. Construction of stable statistical models with internal validity for risk adjustment proved impossible.

Conclusions

The precision of the NSQIP-P dataset has allowed identification of risk factors for shunt infection and for shunt failure without infection that have not been documented previously. Thirty-day shunt outcomes may be useful quality metrics, possibly even without risk adjustment. Whether important variation in 30-day outcomes exists among institutions or among neurosurgeons is yet unknown.

Restricted access

Joseph H. Piatt Jr.

Syringomyelia is frequently found in association with myelomeningocele. Although often asymptomatic, it can, in exceptional cases, cause severe morbidity. The author performed a structured literature review to address the following aspects of this clinical problem.

What is the natural history? There are data concerning the imaging prevalence, the autopsy prevalence, and the prevalence of clinically active syringomyelia among patients with myelomeningocele, but literature provides no description of the course of this condition over time.

What is the clinical significance? That correlations among symptoms, signs, treatments, and imaging findings are poorly described is no surprise in view of the large fraction of patients with syringomyelia who are asymptomatic. There is, however, an impressive mass of anecdotal evidence associating progressive syringomyelia with untreated (or inadequately treated) hydrocephalus.

How to make the diagnosis? There is no disagreement that magnetic resonance imaging is the diagnostic modality of choice, but the literature provides very little guidance about who should undergo this investigation. There is no analysis of the costs and benefits of screening or periodic surveillance.

What is the best treatment? Many surgical procedures have been reported to be useful as components of complex algorithms relating clinical factors and imaging data to treatment recommendations. There have been no controlled studies. There have been no prospective studies. There have been no multiinstitutional studies. No studies in which outcomes have been evaluated using objective, validated instruments. No studies in which the robustness of treatment effects over time have been documented.

The complexity of treatment selection in contemporary practice makes syringomyelia unsuitable for randomized controlled trials of different therapies. Prospective cohort studies are feasible, however, and hold the potential to address many important questions about natural history and patient outcomes.

Restricted access

Joseph H. Piatt Jr.

In this paper, the author presents 2 cases of sagittal synostosis with scaphocephaly that featured ossified scalp hematomas straddling the sagittal suture in the midparietal region. These ossified lesions were originally cephalohematomas. Collection of blood under the pericranium across the midline was possible in these cases because sagittal synostosis had obliterated the sagittal suture and its dense attachment to overlying periosteum. Scaphocephaly very likely exacerbated the difficulty of the deliveries and contributed to the causation of the scalp hemorrhages.

The alternative hypothesis, that ossification of a scalp hematoma immobilized the suture and caused synostosis, is not tenable for reasons that are reviewed. Sagittal synostosis in these 2 instances was not a complication of birth trauma.

Restricted access

Joseph H. Piatt Jr.

Restricted access

Joseph H. Piatt Jr.

✓ A minor modification of the technique of peritoneal cerebrospinal fluid shunt insertion allows more anatomical closure of the abdominal wound and may protect the shunt from contamination by superficial abdominal wound infection.