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Eva Knifed, Julius July and Mark Bernstein

recovery. Limitations of this Study There are limitations in this study. Qualitative research is subjective both in the way the interviews are structured and conducted and in how they are interpreted and analyzed. This type of research is uncommon in the surgical literature. It may be considered less rigorous than quantitative research methodology, but it is valuable in answering questions quantitative methods cannot. All patients were selected from the practice of one neurosurgeon with a teaching hospital practice focused on brain tumors. This factor introduces

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W. Bradford DeLong, Nayak Polissar and Blažej Neradilek

: 205 – 209 , 1990 53 Goldman HB , Appell RA : Voiding dysfunction in women with lumbar disc prolapse . Int Urogynecol J Pelvic Floor Dysfunct 10 : 134 – 138 , 1999 54 Goldsmith MR , Bankhead CR , Austoker J : Synthesising quantitative and qualitative research in evidence-based patient information . J Epidemiol Community Health 61 : 262 – 270 , 2007 55 Greenland S : Can meta-analysis be salvaged? . Am J Epidemiol 140 : 783 – 787 , 1994 56 Grégoire G , Derderian F , Le Lorier J : Selecting the language of the publications

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Shobhan Vachhrajani, Abhaya V. Kulkarni and John R. W. Kestle

in medical malpractice suits . Physician Exec 21 : 10 – 12 , 1995 18 Dahan R , Borkan J , Brown JB , Reis S , Hermoni D , Harris S : The challenge of using the low back pain guidelines: a qualitative research . J Eval Clin Pract 13 : 616 – 620 , 2007 19 Duval M , Desrosiers M : Guidelines for management of acute bacterial rhinosinusitis: impact on Quebec physicians' prescriptions for antibiotics . Otolaryngol Head Neck Surg 136 : 258 – 260 , 2007 20 Farquhar CM , Kofa EW , Slutsky JR : Clinicians' attitudes to

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Jay Riva-Cambrin, Allan S. Detsky, Maria Lamberti-Pasculli, Michael A. Sargent, Derek Armstrong, Rahim Moineddin, D. Douglas Cochrane and James M. Drake

tests . BMJ 323 : 157 – 162 , 2001 7 Deeks JJ , Altman DG : Diagnostic tests 4: likelihood ratios . BMJ 329 : 168 – 169 , 2004 8 Dias MS , Albright AL : Management of hydrocephalus complicating childhood posterior fossa tumors . Pediatr Neurosci 15 : 283 – 290 , 1989 9 Dicicco-Bloom B , Crabtree BF : The qualitative research interview . Med Educ 40 : 314 – 321 , 2006 10 Drake JM : Endoscopic third ventriculostomy in pediatric patients: the Canadian experience . Neurosurgery 60 : 881 – 886 , 2007 11 Gilbertson RJ

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Kathleen Joy Khu, Francesco Doglietto, Ivan Radovanovic, Faisal Taleb, Daniel Mendelsohn, Gelareh Zadeh and Mark Bernstein

for tumor excision; 2) patients were ≥ 18 years of age; 3) patients spoke and understood English well; and 4) patients had no cognitive deficits, either from their brain tumor or otherwise. Sample Size Twenty-five to 30 interviews were sought because it was anticipated that this would be sufficient to achieve data saturation. “Saturation” is a concept in qualitative research describing the situation in which no new concepts arise during successive interviews. 8 Data Collection Two semistructured, open-ended interviews were conducted with each participant

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Daniel Mendelsohn, Nir Lipsman and Mark Bernstein

'Doherty K : Perspectives on engaging the public in the ethics of emerging biotechnologies: from salmon to biobanks to neuroethics . Account Res 15 : 283 – 302 , 2008 24 Sententia W : Neuroethical considerations: cognitive liberty and converging technologies for improving human cognition . Ann N Y Acad Sci 1013 : 221 – 228 , 2004 25 Strauss AL , Corbin JM : Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory ed 2 Thousand Oaks, CA , Sage Publications , 1998 . 101 – 137 26 Swayze VW II : Frontal

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Erin N. Kiehna, Robert M. Starke, Nader Pouratian and Aaron S. Dumont

(TREND), Outbreak Reports and Intervention Studies of Nosocomial Infection (ORION), Consolidated Criteria for Reporting Qualitative Research (COREQ), Quality of Reporting of Meta-analyses (QUOROM), Reporting Recommendations for Tumor Marker Prognostic Studies (REMARK), and CONSORT. 48 Over the past decade, researchers across many fields have changed the way they design, execute, and analyze trials to meet these standards. Randomized controlled trials are considered the gold standard of reporting research because they minimize the bias that authors might interject

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Erlick A. C. Pereira, Sandra G. Boccard, Paulo Linhares, Clara Chamadoira, Maria José Rosas, Pedro Abreu, Virgínia Rebelo, Rui Vaz and Tipu Z. Aziz

an overall significant improvement in quality of life as measured by the SF-36. While improvements in physical function were noted, negligible improvements in social function, vitality, and emotional and mental health were reported. It is difficult to explain these results without undertaking further qualitative research by interviewing the patients, caregivers, and blinded pain physicians who undertook assessments. However, one can postulate first that pain relief alone in an already functionless limb may have contributed little to altering daily activities for

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Kathleen Joy O. Khu and Mark Bernstein

undergo. Finally, Dr. Milian and colleagues used surveys while we used face-to-face interviews, which may allow a richer pursuit of the information sought. However Dr. Milian and colleagues' results do nicely demonstrate one of the important weaknesses of qualitative research: the fact that generalizability may sometimes be limited. Disclosure The authors report no conflict of interest. References 1 Khu K , Doglietto F , Radovanovic I , Taleb F , Mendelsohn D , Zadeh G , : Patients' perceptions of awake and outpatient craniotomy for brain

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Joseph Domino, Connie McGovern, Kate W. C. Chang, Noelle E. Carlozzi and Lynda J. S. Yang

Object

Perinatal disorders are prone to malpractice litigation. Neonatal brachial plexus palsy (NBPP) results from stretching the nerves in the perinatal period and may lead to paresis or paralysis and sensory loss in the affected arm. Little is known about the key factors associated with malpractice litigation by families of patients with NBPP and whether these factors reflect the practice environment or are inherent to the condition. In this study, the authors documented the percentage of families of NBPP patients at a specialty center that had filed a malpractice suit and described the key factors associated with that pursuit of legal action.

Methods

The families/caregivers of 51 patients with NBPP who had presented to the University of Michigan Interdisciplinary Brachial Plexus Program participated in this study. A qualitative research design was applied using both a questionnaire to examine psychosocial factors and a dynamic tool to measure health outcomes from the patient perspective via parent proxy (Patient-Reported Outcomes Measurement Information System [PROMIS] assessment instruments). Statistical analysis included the Fisher exact test, chi-square test, and Student t-test. The study protocol was approved by the University of Michigan institutional review board.

Results

Forty-seven percent of the families pursued malpractice litigation. In comparing patient families that had pursued legal action with those that had not, significant differences were revealed in the perception that the sustained birth injury was unnecessary (p = 0.002), the information received in the perinatal period was inadequate (p = 0.003), family concerns were ignored in the perinatal period (p = 0.005), and family concerns were not adequately addressed (p < 0.001). Sixty-six percent of the families received external advice to pursue legal action. The PROMIS survey revealed significant group differences in depressive symptoms (p = 0.008), fatigue (p = 0.02), pain (p = 0.01), and anger (p = 0.004). In contrast, the extent of NBPP was not associated with malpractice litigation (p = 0.18). Age, sex, and race were not significantly different between litigation and nonlitigation groups.

Conclusions

Physician-controllable factors, such as communication in the perinatal period, are associated with malpractice litigation in NBPP. The perceived level of global disability may affect the pursuit of malpractice litigation, whereas the isolated extent of nerve root involvement and/or upper extremity dysfunction are not significant factors in pursuing litigation. Identifying and ameliorating these factors within the practice environment may decrease the animosity between families and health care providers and improve overall outcome for patients with NBPP.