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Daniel R. Fassett, James S. Harrop, Mitchell Maltenfort, Shiveindra B. Jeyamohan, John D. Ratliff, D. Greg Anderson, Alan S. Hilibrand, Todd J. Albert, Alexander R. Vaccaro and Ashwini D. Sharan

the impact that age and extent of neurological injury has on the mortality rate associated with traumatic SCI. Clinical Material and Methods A database containing the records of all patients treated from 1978 through 2005 at the Delaware Valley Regional Spinal Cord Injury Center at Thomas Jefferson University Hospital was reviewed. Over the 28-year period, 3481 patients were treated for acute penetrating and blunt spinal cord and spine injuries; 412 of these patients were 70 years of age or older when admitted for treatment. Throughout this period a

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Melville R. Klauber, Lawrence F. Marshall, Belinda M. Toole, Sharen L. Knowlton and Sharon A. Bowers

sophisticated emergency medical service system and public education program was implemented. The report of Aprahamian, et al. , 1 associated improvement in salvage of patients with major open intra-abdominal vascular trauma with early intervention of trained paramedical personnel. A recent report by Baxt and Moody 2 from our region indicated that the implementation of helicopter emergency service staffed by physicians who are expert in trauma care might reduce trauma mortality. These reports have led us to review head-injury mortality rates in San Diego County

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Michael F. Stiefel, Alejandro Spiotta, Vincent H. Gracias, Alicia M. Garuffe, Oscar Guillamondegui, Eileen Maloney-Wilensky, Stephanie Bloom, M. Sean Grady and Peter D. LeRoux

alone or both ICP and brain tissue PO 2 monitoring. The primary objective of our analysis was to determine whether the patient mortality rate was reduced when a brain tissue PO 2 monitor was used to guide treatment of TBI. Clinical Material and Methods Patient Population Patients with severe TBI who had been admitted to the HUP, a Level I trauma center, between January 2000 and July 2002 were considered for inclusion in this study. Patients were evaluated as part of an observational prospective database with Institutional Review Board approval. Inclusion

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Christopher L. Taylor, Zhong Yuan, Warren R. Selman, Robert A. Ratcheson and Alfred A. Rimm

T he mortality rate from subarachnoid hemorrhage (SAH) is as high as 50%, 21, 24 and many patients who survive this devastating illness experience significant morbidity. Patients 65 years of age or older are at a particularly high risk for death from aneurysmal bleeding. 10, 11, 13, 15, 20, 25, 29 This increased risk has acquired greater significance because this age group constitutes an increasingly large segment of the U.S. population. An inverse relationship between the number of surgical procedures performed and mortality rates has been well described

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Edward R. Smith, William E. Butler and Fred G. Barker II

T here is increasing evidence that mortality rates are lower when complex medical or surgical procedures are performed at high-volume centers or by high-volume providers. For example, in-hospital mortality rates are three- to fourfold higher after pancreatic duodenectomies performed at low-volume hospitals (0–two procedures/year) compared with high-volume hospitals (< five procedures/year). 8 Similar results have been documented for other complex cancer operations, 7 , 21 cardiovascular operations 9 (including pediatric cardiac surgeries), 17, 24, 38, 40

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Christopher L. Taylor, Zhong Yuan, Warren R. Selman, Robert A. Ratcheson and Alfred A. Rimm

The risk of disability and death and the cost of medical care are particularly high for patients with aneurysmal subarachnoid hemorrhage (SAH) who are 65 years of age or older. A retrospective analysis of 47,408 Medicare patients treated over an 8-year period was performed to determine whether a relationship exists between the mortality rate and surgical volume for older patients with SAH. The mortality rate, length of stay in the hospital, and cost of treatment for patients with SAH in California and New York were also compared. The mortality rate was 14.3% for patients with SAH who were 65 years old or older and who were treated surgically in hospitals in which an average of five or more craniotomies were performed per year; in hospitals averaging between one and five craniotomies annually the mortality rate was 18.4%; and in those averaging less than one such operation per year the rate was 20.5% (trend p = 0.01). There was no difference in the mortality rate for patients in California versus the rate for those in New York. Surgically and medically treated patients, respectively, left the hospital an average of 6.7 and 5.1 days sooner in California than in New York. The unadjusted average reimbursement from Medicare to hospitals for surgically treated patients averaged $1468 more in New York than in California (p < 0.0001), but was equivalent for medically treated patients in the two states. The mortality rate in older patients who are treated surgically for SAH may be inversely correlated with the annual number of craniotomies performed for SAH in patients 65 years of age or older at a given institution. Hospital stays for patients with SAH are significantly shorter in California than in New York.

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Mark A. Keroack, Steven J. Meurer and Allison Lee Sabel

T o the E ditor : In an article published online in July by Hammers et al. (Hammers R, Anzalone S, Sinacore J, et al: Neurosurgical mortality rates: what variables affect mortality within a single institution and within a national database? Clinical article. J Neurosurg 112: 257–264, February, 2010), the authors utilize data from the University HealthSystem Consortium Clinical Database (UHC CDB) to argue that “there is no gold standard for making comparative mortality index measurements in neurosurgery.” We are writing to correct a few factual errors

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Roddy O'Kane, Ryan Mathew, Tom Kenny, Charles Stiller and Paul Chumas

performance. Various outcome measures have been used, 29 , 30 many of which are procedure specific. In neurosurgery these include reduced frequency of seizures after epilepsy surgery, 42 frequency of postoperative CSF shunt infection, 2 and frequency of transfusion associated with surgery for craniosynostosis. 2 Understandably, operative mortality rate remains one of the most objective and concrete outcome measurements, and many surgical specialties routinely use the 30-day operative mortality rate. 7 , 9 Somewhat surprisingly, this outcome measure has not been widely

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DeWitte T. Cross III, David L. Tirschwell, Mary Ann Clark, Dan Tuden, Colin P. Derdeyn, Christopher J. Moran and Ralph G. Dacey Jr.

C ase volume is related to outcome in a variety of procedures. For carotid endarterectomy, craniotomy for aneurysm clip placement, coronary artery bypass grafting, coronary angioplasty, pancreatic resection, joint replacement surgery, esophagectomy, pneumonectomy, and other surgical procedures, higher case volumes are correlated with lower mortality rates. 1, 3–6, 8, 11, 16–19, 24–26, 30 When a case volume—mortality rate relationship is identified, it may be possible to use that relationship to improve outcomes. Policies implemented in Canada and New York to

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Paul Kalanithi, Ryan D. Schubert, Shivanand P. Lad, Odette A. Harris and Maxwell Boakye

second part of the study (Part 2), we used a multivariate logistic regression model to analyze cost, morbidity, and mortality rate, and identify factors that may affect mortality rate following surgery over a 10-year period. Inclusion criteria and statistical methods are discussed separately for each analysis. Methods Inclusion Criteria Part 1 of the study was designed to investigate trends in admissions, cost, LOS, and inhospital deaths. All patients from 1993 to 2006 who had a primary diagnosis of traumatic SDH (ICD-9 codes 852.20–852.39, SDH following