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Abhijith V. Matur, Laura B. Ngwenya, and Charles J. Prestigiacomo

Motor vehicle collisions (MVCs) are a significant cause of head injuries today, but efforts to manage and prevent these injuries extend as far back as the beginning of modern neurosurgery itself. Head trauma in MVCs occurred as far back as 1899, and the surgical literature of the time mentions several cases of children being struck by passing automobiles. By the 1930s, Dr. Claire L. Straith, a Detroit plastic surgeon, recommended changes to automobile design after seeing facial injuries and depressed skull fractures that resulted from automobile accidents. During World War II, Sir Hugh Cairns, a British neurosurgeon, demonstrated the efficacy of motorcycle helmets in preventing serious head injury. In the 1950s, Dr. Frank H. Mayfield, a Cincinnati neurosurgeon on the trauma committee of the American College of Surgeons, made several recommendations, such as adding padded dashboards and seatbelts, to make automobiles safer. Ford implemented the recommendations from Dr. Mayfield and others into a safety package for the 1956 models. Significant work has also been done to prevent head injury in motorsports. Efforts by surgeons, especially neurosurgeons, to prevent head injury in MVCs have saved countless lives, although it is a less frequently celebrated achievement.

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Laura B. Ngwenya and E. Antonio Chiocca

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Laura B. Ngwenya and E. Antonio Chiocca

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Laura B. Ngwenya and E. Antonio Chiocca

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Jed A. Hartings, Laura B. Ngwenya, Christopher P. Carroll, and Brandon Foreman

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Fatima Khalid, George L. Yang, Jennifer L. McGuire, Matthew J. Robson, Brandon Foreman, Laura B. Ngwenya, and John N. Lorenz

Although there is a substantial amount of research on the neurological consequences of traumatic brain injury (TBI), there is a knowledge gap regarding the relationship between TBI and the pathophysiology of organ system dysfunction and autonomic dysregulation. In particular, the mechanisms or incidences of renal or cardiac complications after TBI are mostly unknown. Autonomic dysfunction following TBI exacerbates secondary injury and may contribute to nonneurologial complications that prolong hospital length of stay. Gaining insights into the mechanisms of autonomic dysfunction can guide advancements in monitoring and treatment paradigms to improve acute survival and long-term prognosis of TBI patients. In this paper, the authors will review the literature on autonomic dysfunction after TBI and possible mechanisms of paroxysmal sympathetic hyperactivity. Specifically, they will discuss the link among the brain, heart, and kidneys and review data to direct future research on and interventions for TBI-induced autonomic dysfunction.

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Laura B. Ngwenya, Catherine G. Suen, Phiroz E. Tarapore, Geoffrey T. Manley, and Michael C. Huang

OBJECTIVE

Blood loss and moderate anemia are common in patients with traumatic brain injury (TBI). However, despite evidence of the ill effects and expense of the transfusion of packed red blood cells, restrictive transfusion practices have not been universally adopted for patients with TBI. At a Level I trauma center, the authors compared patients with TBI who were managed with a restrictive (target hemoglobin level > 7 g/dl) versus a liberal (target hemoglobin level > 10 g/dl) transfusion protocol. This study evaluated the safety and cost-efficiency of a hospital-wide change to a restrictive transfusion protocol.

METHODS

A retrospective analysis of patients with TBI who were admitted to the intensive care unit (ICU) between January 2011 and September 2015 was performed. Patients < 16 years of age and those who died within 24 hours of admission were excluded. Demographic data and injury characteristics were compared between groups. Multivariable regression analyses were used to assess hospital outcome measures and mortality rates. Estimates from an activity-based cost analysis model were used to detect changes in cost with transfusion protocol.

RESULTS

A total of 1565 patients with TBI admitted to the ICU were included in the study. Multivariable analysis showed that a restrictive transfusion strategy was associated with fewer days of fever (p = 0.01) and that patients who received a transfusion had a larger fever burden. ICU length of stay, ventilator days, incidence of lung injury, thromboembolic events, and mortality rates were not significantly different between transfusion protocol groups. A restrictive transfusion protocol saved approximately $115,000 annually in hospital direct and indirect costs.

CONCLUSIONS

To the authors’ knowledge, this is the largest study to date to compare transfusion protocols in patients with TBI. The results demonstrate that a hospital-wide change to a restrictive transfusion protocol is safe and cost-effective in patients with TBI.

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Diana T. Le, Kinsey A. Barhorst, James Castiglione, George L. Yang, Sanjit J. Shah, Sarah S. Harlan, Shaun P. Keegan, Roman A. Jandarov, Laura B. Ngwenya, and Charles J. Prestigiacomo

OBJECTIVE

Blunt cerebrovascular injury (BCVI) is associated with high rates of neurological morbidity and mortality. The detection and management of BCVI has improved with advances in imaging and sensitive screening protocols. Few studies have explored how these injuries specifically affect the geriatric population. The purpose of this retrospective analysis was to investigate the presentation and prognosis of BCVI in the elderly population and to assess its clinical implications in the management of these patients.

METHODS

All patients presenting to the University of Cincinnati (UC) level I trauma center between February 2017 and December 2019 were screened for BCVI and entered into the prospectively maintained UC Neurotrauma Registry. Patients with BCVI confirmed by CT angiography underwent retrospective chart reviews to collect information regarding demographics, positive screening criteria, cause of injury, antithrombotic agent, injury location, Denver Grading Scale, hospital and ICU length of stay, and discharge disposition. Patients were divided into geriatric (age ≥ 65 years) and adult (age < 65 years) subgroups. Continuous variables were analyzed using the Student t-test and categorical variables with the Pearson chi-square test.

RESULTS

Of 124 patients with BCVI, stratification by age yielded 23 geriatric and 101 adult patients. Injury in the geriatric group was associated with significantly higher mortality (p = 0.0194). The most common cause of injury in the elderly was falls (74%, 17/23; p < 0.0001), whereas motor vehicle accidents were most common in the adult group (38%, 38/100; p = 0.0642). With respect to the location of injury, carotid (p = 0.1171) and vertebral artery (p = 0.6981) injuries did not differ significantly for the geriatric group. The adult population presented more often with Denver grade I injuries (p < 0.0001), whereas the geriatric population presented with grade IV injuries (p = 0.0247). Elderly patients were more likely to be discharged to skilled nursing facilities (p = 0.0403) and adults to home or self-care (p = 0.0148).

CONCLUSIONS

This study is the first to characterize BCVI to all cervical and intracranial vessels in the geriatric population. Older age at presentation is significantly associated with greater severity, morbidity, and mortality from injury, with no preference for the particular artery injured. These findings carry important clinical implications for adapting practice in an aging population.

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Sanjit Shah, George L. Yang, Diana T. Le, Christina Gerges, James M. Wright, Ann M. Parr, Joseph S. Cheng, and Laura B. Ngwenya

The Emergency Medical Treatment and Active Labor Act (EMTALA) protects patient access to emergency medical treatment regardless of insurance or socioeconomic status. A significant result of the COVID-19 pandemic has been the rapid acceleration in the adoption of telemedicine services across many facets of healthcare. However, very little literature exists regarding the use of telemedicine in the context of EMTALA. This work aimed to evaluate the potential to expand the usage of telemedicine services for neurotrauma to reduce transfer rates, minimize movement of patients across borders, and alleviate the burden on tertiary care hospitals involved in the care of patients with COVID-19 during a global pandemic. In this paper, the authors outline EMTALA provisions, provide examples of EMTALA violations involving neurosurgical care, and propose guidelines for the creation of telemedicine protocols between referring and consulting institutions.

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Rimal H. Dossani, Danielle Terrell, Jennifer A. Kosty, Robert C. Ross, Audrey Demand, Elizabeth Wild, Racheal Peterson, Laura B. Ngwenya, Deborah L. Benzil, and Christina Notarianni

OBJECTIVE

The objective of this study was to evaluate whether there are disparities in academic rank and promotion between men and women neurosurgeons.

METHODS

The profiles of faculty members from 50 academic neurosurgery programs were reviewed to identify years in practice, number of PubMed-indexed publications, Doctor of Philosophy (PhD) attainment, and academic rank. The number of publications at each academic rank was compared between men and women after controlling for years in practice by using a negative binomial regression model. The relationship between gender and each academic rank was also determined after controlling for clustering at the institutional level, years in practice, and number of publications.

RESULTS

Of 841 faculty members identified, 761 (90%) were men (p = 0.0001). Women represented 12% of the assistant and associate professors but only 4% of the full professors. Men and women did not differ in terms of the percentage holding a PhD, years in practice, or number of publications at any academic rank. After controlling for years in practice and clustering at the facility level, the authors found that men were twice as likely as women to be named full professor (OR 2.2, 95% CI 1.09–4.44, p = 0.03). However, when institution, years in practice, PhD attainment, h-index, and number of publications were considered, men and women were equally likely to attain full professorship (OR 0.9, 95% CI 0.42–1.93).

CONCLUSIONS

Data analysis of the top neurosurgery programs suggests that although there are fewer women than men holding positions in academic neurosurgery, faculty rank attainment does not seem to be influenced by gender.