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Madeleine P. de Lotbiniere-Bassett, Jay Riva-Cambrin, and Patrick J. McDonald

OBJECTIVE

An increasing amount of funding in neurosurgery research comes from industry, which may create a conflict of interest (COI) and the potential to bias results. The reporting and handling of COIs have become difficult, particularly as explicit policies themselves and definitions thereof continue to vary between medical journals. In this study, the authors sought to evaluate the prevalence and comprehensiveness of COI policies among leading neurosurgical journals.

METHODS

The authors conducted a cross-sectional study of publicly available online disclosure policies in the 20 highest-ranking neurosurgical journals, as determined by Google Scholar Metrics, in July 2016.

RESULTS

Overall, 89.5% of the highest-impact neurosurgical journals included COI policy statements. Ten (53%) journals requested declaration of nonfinancial conflicts, while 2 journals specifically set a time period for COIs. Sixteen journals required declaration from the corresponding author, 13 from all authors, 6 from reviewers, and 5 from editors. Four journals were included in the International Committee of Medical Journal Editors (ICMJE) list of publications that follow the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (currently known as Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals). Five journal policies included COI declaration verification, management, or enforcement. The neurosurgery journals with more comprehensive COI policies were significantly more likely to have higher h5-indices (p = 0.003) and higher impact factors (p = 0.01).

CONCLUSIONS

In 2016, the majority of, but not all, high-impact neurosurgical journals had publically available COI disclosure policies. Policy inclusiveness and comprehensiveness varied substantially across neurosurgical journals, but COI comprehensiveness was associated with other established markers of individual journals’ favorability and influence, such as impact factor and h5-index.

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Patrick J. McDonald, Charles C. Matouk, Blake Papsin, and James T. Rutka

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Michael J. Ellis, Colin J. Kazina, Marc R. Del Bigio, and Patrick J. McDonald

✓Shunt failure is commonly associated with infection or mechanical obstruction of the shunt system. The presence of eosinophilia in the cerebrospinal fluid (CSF) has been associated with CSF shunt failure and may be related to both latex and shunt allergies. The authors describe the case of a child with a latex allergy who presented with 10 episodes of shunt failure over a period of 93 months. Cerebrospinal fluid sampling demonstrated persistent eosinophilia (3–36%) and negative cultures. Pathological examination of the ventricular catheter on 3 occasions demonstrated mechanical obstruction by inflammatory debris consisting largely of eosinophils and multinucleated giant cells. On the suspicion that the child might have some uncharacterized allergy to the shunt hardware, shunt replacement was performed using an “extracted” shunt system. The child has remained free of shunt malfunction for > 2 years since the last surgery. Immune responses to unpolymerized silicone are discussed.

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Michael J. Ellis, Patrick J. McDonald, Dean Cordingley, Behzad Mansouri, Marco Essig, and Lesley Ritchie

The decision to advise an athlete to retire from sports following sports-related concussion (SRC) remains a persistent challenge for physicians. In the absence of strong empirical evidence to support recommendations, clinical decision making must be individualized and should involve a multidisciplinary team of experts in concussion and traumatic brain injury. Although previous authors have advocated for a more conservative approach to these issues in child and adolescent athletes, there are few reports outlining considerations for this process among this unique population. Here, the authors use multiple case illustrations to discuss 3 subgroups of clinical considerations for sports retirement among pediatric SRC patients including the following: those with structural brain abnormalities identified on neuroimaging, those presenting with focal neurological deficits and abnormalities on physical examination, and those in whom the cumulative or prolonged effects of concussion are suspected or demonstrated. The authors' evolving multidisciplinary institutional approach to return-to-play and retirement decision making in pediatric SRC is also presented.

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Michael J. Ellis, Jeff Leiter, Thomas Hall, Patrick J. McDonald, Scott Sawyer, Norm Silver, Martin Bunge, and Marco Essig

OBJECT

The goal in this review was to summarize the results of clinical neuroimaging studies performed in patients with sports-related concussion (SRC) who were referred to a multidisciplinar ypediatric concussion program.

METHODS

The authors conducted a retrospective review of medical records and neuroimaging findings for all patients referred to a multidisciplinary pediatric concussion program between September 2013 and July 2014. Inclusion criteria were as follows: 1) age ≤ 19 years; and 2) physician-diagnosed SRC. All patients underwent evaluation and follow-up by the same neurosurgeon. The 2 outcomes examined in this review were the frequency of neuroimaging studies performed in this population (including CT and MRI) and the findings of those studies. Clinical indications for neuroimaging and the impact of neuroimaging findings on clinical decision making were summarized where available. This investigation was approved by the local institutional ethics review board.

RESULTS

A total of 151 patients (mean age 14 years, 59% female) were included this study. Overall, 36 patients (24%) underwent neuroimaging studies, the results of which were normal in 78% of cases. Sixteen percent of patients underwent CT imaging; results were normal in 79% of cases. Abnormal CT findings included the following: arachnoid cyst (1 patient), skull fracture (2 patients), suspected intracranial hemorrhage (1 patient), and suspected hemorrhage into an arachnoid cyst (1 patient). Eleven percent of patients underwent MRI; results were normal in 75% of cases. Abnormal MRI findings included the following: intraparenchymal hemorrhage and sylvian fissure arachnoid cyst (1 patient); nonhemorrhagic contusion (1 patient); demyelinating disease (1 patient); and posterior fossa arachnoid cyst, cerebellar volume loss, and nonspecific white matter changes (1 patient).

CONCLUSIONS

Results of clinical neuroimaging studies are normal in the majority of pediatric patients with SRC. However, in selected cases neuroimaging can provide information that impacts decision making about return to play and retirement from the sport.

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Mandeep S. Tamber, John R. W. Kestle, Ron W. Reeder, Richard Holubkov, Jessica Alvey, Samuel R. Browd, James M. Drake, Abhaya V. Kulkarni, David D. Limbrick Jr., Patrick J. McDonald, Curtis J. Rozzelle, Tamara D. Simon, Robert Naftel, Chevis N. Shannon, John C. Wellons III, William E. Whitehead, Jay Riva-Cambrin, and for the Hydrocephalus Clinical Research Network

OBJECTIVE

Analysis of temporal trends in patient populations and procedure types may provide important information regarding the evolution of hydrocephalus treatment. The purpose of this study was to use the Hydrocephalus Clinical Research Network’s Core Data Project to identify meaningful trends in patient characteristics and the surgical management of pediatric hydrocephalus over a 9-year period.

METHODS

The Core Data Project prospectively collected patient and procedural data on the study cohort from 9 centers between 2008 and 2016. Logistic and Poisson regression were used to test for significant temporal trends in patient characteristics and new and revision hydrocephalus procedures.

RESULTS

The authors analyzed 10,149 procedures in 5541 patients. New procedures for hydrocephalus (shunt or endoscopic third ventriculostomy [ETV]) decreased by 1.5%/year (95% CI −3.1%, +0.1%). During the study period, new shunt insertions decreased by 6.5%/year (95% CI −8.3%, −4.6%), whereas new ETV procedures increased by 12.5%/year (95% CI 9.3%, 15.7%). Revision procedures for hydrocephalus (shunt or ETV) decreased by 4.2%/year (95% CI −5.2%, −3.1%), driven largely by a decrease of 5.7%/year in shunt revisions (95% CI −6.8%, −4.6%). Concomitant with the observed increase in new ETV procedures was an increase in ETV revisions (13.4%/year, 95% CI 9.6%, 17.2%). Because revisions decreased at a faster rate than new procedures, the Revision Quotient (ratio of revisions to new procedures) for the Network decreased significantly over the study period (p = 0.0363). No temporal change was observed in the age or etiology characteristics of the cohort, although the proportion of patients with one or more complex chronic conditions significantly increased over time (p = 0.0007).

CONCLUSIONS

Over a relatively short period, important changes in hydrocephalus care have been observed. A significant temporal decrease in revision procedures amid the backdrop of a more modest change in new procedures appears to be the most notable finding and may be indicative of an improvement in the quality of surgical care for pediatric hydrocephalus. Further studies will be directed at elucidation of the possible drivers of the observed trends.

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Jonathan Pindrik, Jay Riva-Cambrin, Abhaya V. Kulkarni, Jessica S. Alvey, Ron W. Reeder, Ian F. Pollack, John C. Wellons III, Eric M. Jackson, Curtis J. Rozzelle, William E. Whitehead, David D. Limbrick Jr., Robert P. Naftel, Chevis Shannon, Patrick J. McDonald, Mandeep S. Tamber, Todd C. Hankinson, Jason S. Hauptman, Tamara D. Simon, Mark D. Krieger, Richard Holubkov, John R. W. Kestle, and for the Hydrocephalus Clinical Research Network

OBJECTIVE

Few studies have addressed surgical resource utilization—surgical revisions and associated hospital admission days—following shunt insertion or endoscopic third ventriculostomy (ETV) with or without choroid plexus cauterization (CPC) for CSF diversion in hydrocephalus. Study members of the Hydrocephalus Clinical Research Network (HCRN) investigated differences in surgical resource utilization between CSF diversion strategies in hydrocephalus in infants.

METHODS

Patients up to corrected age 24 months undergoing initial definitive treatment of hydrocephalus were reviewed from the prospectively maintained HCRN Core Data Project (Hydrocephalus Registry). Postoperative courses (at 1, 3, and 5 years) were studied for hydrocephalus-related surgeries (primary outcome) and hospital admission days related to surgical revision (secondary outcome). Data were summarized using descriptive statistics and compared using negative binomial regression, controlling for age, hydrocephalus etiology, and HCRN center. The study population was organized into 3 groups (ETV alone, ETV with CPC, and CSF shunt insertion) during the 1st postoperative year and 2 groups (ETV alone and CSF shunt insertion) during subsequent years due to limited long-term follow-up data.

RESULTS

Among 1090 patients, the majority underwent CSF shunt insertion (CSF shunt, 83.5%; ETV with CPC, 10.0%; and ETV alone, 6.5%). Patients undergoing ETV with CPC had a higher mean number of revision surgeries (1.2 ± 1.6) than those undergoing ETV alone (0.6 ± 0.8) or CSF shunt insertion (0.7 ± 1.3) over the 1st year after surgery (p = 0.005). At long-term follow-up, patients undergoing ETV alone experienced a nonsignificant lower mean number of revision surgeries (0.7 ± 0.9 at 3 years and 0.8 ± 1.3 at 5 years) than those undergoing CSF shunt insertion (1.1 ± 1.9 at 3 years and 1.4 ± 2.6 at 5 years) and exhibited a lower mean number of hospital admission days related to revision surgery (3.8 ± 10.3 vs 9.9 ± 27.0, p = 0.042).

CONCLUSIONS

Among initial treatment strategies for hydrocephalus, ETV with CPC yielded a higher surgical revision rate within 1 year after surgery. Patients undergoing ETV alone exhibited a nonsignificant lower mean number of surgical revisions than CSF shunt insertion at 3 and 5 years postoperatively. Additionally, the ETV-alone cohort demonstrated significantly fewer hospital admission days related to surgical management of hydrocephalus within 3 years after surgery. These findings suggest a time-dependent benefit of ETV over CSF shunt insertion regarding surgical resource utilization.

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Jacob K. Greenberg, Donna B. Jeffe, Christopher R. Carpenter, Yan Yan, Jose A. Pineda, Angela Lumba-Brown, Martin S. Keller, Daniel Berger, Robert J. Bollo, Vijay M. Ravindra, Robert P. Naftel, Michael C. Dewan, Manish N. Shah, Erin C. Burns, Brent R. O’Neill, Todd C. Hankinson, William E. Whitehead, P. David Adelson, Mandeep S. Tamber, Patrick J. McDonald, Edward S. Ahn, William Titsworth, Alina N. West, Ross C. Brownson, and David D. Limbrick Jr.

OBJECTIVE

There remains uncertainty regarding the appropriate level of care and need for repeating neuroimaging among children with mild traumatic brain injury (mTBI) complicated by intracranial injury (ICI). This study’s objective was to investigate physician practice patterns and decision-making processes for these patients in order to identify knowledge gaps and highlight avenues for future investigation.

METHODS

The authors surveyed residents, fellows, and attending physicians from the following pediatric specialties: emergency medicine; general surgery; neurosurgery; and critical care. Participants came from 10 institutions in the United States and an email list maintained by the Canadian Neurosurgical Society. The survey asked respondents to indicate management preferences for and experiences with children with mTBI complicated by ICI, focusing on an exemplar clinical vignette of a 7-year-old girl with a Glasgow Coma Scale score of 15 and a 5-mm subdural hematoma without midline shift after a fall down stairs.

RESULTS

The response rate was 52% (n = 536). Overall, 326 (61%) respondents indicated they would recommend ICU admission for the child in the vignette. However, only 62 (12%) agreed/strongly agreed that this child was at high risk of neurological decline. Half of respondents (45%; n = 243) indicated they would order a planned follow-up CT (29%; n = 155) or MRI scan (19%; n = 102), though only 64 (12%) agreed/strongly agreed that repeat neuroimaging would influence their management. Common factors that increased the likelihood of ICU admission included presence of a focal neurological deficit (95%; n = 508 endorsed), midline shift (90%; n = 480) or an epidural hematoma (88%; n = 471). However, 42% (n = 225) indicated they would admit all children with mTBI and ICI to the ICU. Notably, 27% (n = 143) of respondents indicated they had seen one or more children with mTBI and intracranial hemorrhage demonstrate a rapid neurological decline when admitted to a general ward in the last year, and 13% (n = 71) had witnessed this outcome at least twice in the past year.

CONCLUSIONS

Many physicians endorse ICU admission and repeat neuroimaging for pediatric mTBI with ICI, despite uncertainty regarding the clinical utility of those decisions. These results, combined with evidence that existing practice may provide insufficient monitoring to some high-risk children, emphasize the need for validated decision tools to aid the management of these patients.

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Jason S. Hauptman, John Kestle, Jay Riva-Cambrin, Abhaya V. Kulkarni, Samuel R. Browd, Curtis J. Rozzelle, William E. Whitehead, Robert P. Naftel, Jonathan Pindrik, David D. Limbrick Jr., James Drake, John C. Wellons III, Mandeep S. Tamber, Chevis N. Shannon, Tamara D. Simon, Ian F. Pollack, Patrick J. McDonald, Mark D. Krieger, Jason Chu, Todd C. Hankinson, Eric M. Jackson, Jessica S. Alvey, Ron W. Reeder, Richard Holubkov, and for the Hydrocephalus Clinical Research Network

OBJECTIVE

The primary objective of this study was to use the prospective Hydrocephalus Clinical Research Network (HCRN) registry to determine clinical predictors of fast time to shunt failure (≤ 30 days from last revision) and ultrafast time to failure (≤ 7 days from last revision).

METHODS

Revisions (including those due to infection) to permanent shunt placements that occurred between April 2008 and November 2017 for patients whose entire shunt experience was recorded in the registry were analyzed. All registry data provided at the time of initial shunt placement and subsequent revision were reviewed. Key variables analyzed included etiology of hydrocephalus, age at time of initial shunt placement, presence of slit ventricles on imaging at revision, whether the ventricles were enlarged at the time of revision, and presence of prior fast failure events. Univariable and multivariable analyses were performed to find key predictors of fast and ultrafast failure events.

RESULTS

A cohort of 1030 patients with initial shunt insertions experienced a total of 1995 revisions. Of the 1978 revision events with complete records, 1216 (61.5%) shunts remained functional for more than 1 year, and 762 (38.5%) failed within 1 year of the procedure date. Of those that failed within 1 year, 423 (55.5%) failed slowly (31–365 days) and 339 (44.5%) failed fast (≤ 30 days). Of the fast failures, 131 (38.6%) were ultrafast (≤ 7 days). In the multivariable analysis specified a priori, etiology of hydrocephalus (p = 0.005) and previous failure history (p = 0.011) were independently associated with fast failure. Age at time of procedure (p = 0.042) and etiology of hydrocephalus (p = 0.004) were independently associated with ultrafast failure. These relationships in both a priori models were supported by the data-driven multivariable models as well.

CONCLUSIONS

Neither the presence of slit ventricle syndrome nor ventricular enlargement at the time of shunt failure appears to be a significant predictor of repeated, rapid shunt revisions. Age at the time of procedure, etiology of hydrocephalus, and the history of previous failure events seem to be important predictors of fast and ultrafast shunt failure. Further work is required to understand the mechanisms of these risk factors as well as mitigation strategies.